Your Information
Full Name
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First Name
Last Name
Mailing Address
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Street Address
Street Address Line 2
City
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Postal / Zip Code
Email Address
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example@example.com
Phone Number
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Please enter a valid phone number.
Alternate Phone Number
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Preferred Method of Contact
Email
Phone
Mail
Alternate Format (e.g. Braille, Large Print, or Translated Version)
Alternate 'Preferred Method of Contact' Requested (if applicable)
Representative (if applicable)- COMPLETE ONLY If you are represented by someone concerning this complaint, please provide their information below.
Complaint Details
Date of the incident
*
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Month
-
Day
Year
Date
Description of Incident - Please describe what happened, including any interactions related to your service animal (if applicable), staff names, or locations involved.
*
Approximate Time of Incident
*
Hour Minutes
AM
PM
AM/PM Option
Basis of Complaint (check all that apply)
*
Race/Color
National Origin
Disability (ADA/Section 504)
Retaliation
Website/Digital Accessibility
Service Animal Issue (Access or Treatment)
Other
If Basis of Complaint is 'Other,' please specify:
Agency or Department Involved
Executive Office / Commission
Communications & Public Affairs
Port Operations
Ferry Services
Security & Vessels
Projects & Infrastructure
Finance & Administration
Human Resources
External Vendor / Contractor
Website / Digital Accessibility
Other
If Agency or Department involved is 'Other,' please specify:
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Have you filed this complaint with another agency or court?
Yes
No
If prior action taken, please provide the Agency Name, Contact Person, Date Filed, and Status.
Accessibility Accommodations
Do you require any accommodations during the review process (e.g., large print, Braille, interpreter, relay service)?
Yes
No
If accessibility accommodations required is 'Yes,' please specify:
Signature and Certification
By typing my name below, I certify that the information provided is true and correct to the best of my knowledge. I understand this complaint and any supporting documentation may be shared with the entity alleged to have violated federal civil-rights requirements.
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Typed Signature serves as electronic signature.
Electronic Signature Authorization
*
Yes, I understand that by typing my name below, I am providing my legal electronic signature under the U.S. Electronic Signatures in Global and National Commerce Act (E-SIGN Act), 15 U.S.C. § 7001 et seq.
Today's Date
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-
Month
-
Day
Year
Date
By submitting this form, I certify that the information provided is true and correct to the best of my knowledge. I understand that the Port will review and process my complaint in accordance with its ADA & Accessibility Policy, Service Animal Accommodation Policy, Title VI Civil Rights Policy, and Privacy Policy, and that the information I provide will be used solely for the purpose of investigating and responding to this complaint.
I Agree
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