Non-Discrimination Complaint Form

Non-Discrimination Complaint Form

We value your voice. Please use this form to share any concerns related to disability access (ADA) or discrimination based on race, color, or national origin (Title VI).
Complainant Information

You may submit this form anonymously/ Providing contact information will allow us to follow up with you.
Name (Optional)

First NameLast Name
E-mail (Optional)
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Method of Contact:
Details of the Complaint

Use the following components to describe details of your complaint.
Date of the incident: Date*
Time of the incident (if known):Time*
Location of the incident: Address*
Name(s) and title(s) of staff or individuals involved (if known): Name(s)*
Describe Your Complaint:
Should be Empty:

Complainant Information