ADA & Title VI Complaint Form

  • ADA & Title VI Complaint Form

    Use this form to submit an ADA and Title VI complaint. All fields are optional unless an asterisk (*) indicates a field is required. Important Notice: To protect your rights, your complaint must be filed within 180 days following the date of the alleged discrimination. Failure to file within 180 days may result in dismissal of the complaint. You may attach any additional written materials or other information that you think is relevant to your complaint to this form.

  • BackgroundThis form is used for both Title VI and Americans with Disabilities Act (ADA) complaints.The Civil Rights of 1964 (Title VI) identifies the three classes protected by Title VI—race, color, and national origin—and allow the complainant to select one or more of those protected classes as the basis/bases for discrimination. If any of the Limited English Proficient (LEP) populations in our service area meet the Safe Harbor threshold, then the procedure will be provided in English and in any other language(s) spoken by LEP populations that meet the Safe Harbor Threshold.The Americans with Disabilities Act of 1990 (ADA), provides protection that no individual with a disability shall on the basis of disability, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any federally funded program, service, or activity.Community Transit Services is committed to providing non-discriminatory service to ensure that no person is excluded from participation in, or denied the benefits of, or subjected to discrimination in the receipt of its services on the basis of race, color, or national origin as protected by Title VI of the Civil Rights Act of 1964 (Title VI) as well as providing protection that no individual with a disability shall on the basis of disability, be excluded from participation in, be denied the benefits of, or be subjected to discrimination as stated in the Americans with Disabilities Act of 1990 (ADA).If you feel that you have been discriminated against, please provide the following necessary information to facilitate the processing of your complaint. If assistance is required to complete the form, or if you have questions, please do not hesitate to call the ADA/Title VI Coordinator at 419-868-7433.

  • Complaint Information

  • Complaint Type
  • Format: (000) 000-0000.
  • Additional Formats Needed

  • Third-Party Filing Details

  • Are you filing this complaint on your own behalf?*
  • Third-party permission confirmation

  • Discrimination Details

  • Basis of discrimination*
  • Date of the alleged discrimination*
     - -
  • Have you previously filed an ADA and/or Title VI complaint with this agency?*

  • Other Filings and Agency Contact

  • Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?*
  • Other filing locations
  • Format: (000) 000-0000.
  • If you have filed elsewhere, please provide the other agency or court contact details above.

  • Respondent and Signature

  • Format: (000) 000-0000.
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  • Date*
     - -
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