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Title VI Complaint Form

2. Complainant Information

4. Name

5. Email Address

7. Address

9. City

10. State

11. Zip Code

13. Phone Number

17. Incident Information

19. Date and Time of Incident
    Date and Time of Incident

    Date and Time of Incident

    Please detail incident report in the section below.

20. Location of Incident

    Please provide the location of incident.

22. Type of Discrimination *

    1. Race
    2. Religion
    3. Color
    4. Gender
    5. National Origin (Including Limited English Proficiency)
    6. Marital Status
    7. Age
    8. Disability
    9. Pregnancy
    10. Sexual Orientation
    11. Gender Identity or Expression
    12. Genetic Information
    13. Veteran Status
    14. Other Protected Status

    Please check all options that are applicable to your incident.

23. Other Protect Status

    If you choose Other Protected Status please list that discrimination

25. Description of Incident

    Please detail the incident

27. Please list the names and contact information of any witnesses of the incident

29. Witness Information

    Please put witness name and best number to contact this person

30. Witness Information

    Please put witness name and best number to contact this person

31. Witness Information

    Please put witness name and best number to contact this person

33. Have you filed a complaint with any other federal, state, or local agencies?*
    -- Select One --Yes No

    Please one option only.

35. Agency

36. Contact Name

38. Address

40. City

41. State

42. Zip Code

44. Phone Number

48. Preparer Information
    If complaint form is being prepared by someone who was not involved in the dispute, please fill out the requested information below. If complainant is completing this form, they are exempt from this section.

    If complaint form is being prepared by someone who was not involved in the dispute, please fill out the requested information below. If complainant is completing this form, they are exempt from this section.

50. Name

51. Email Address

53. Phone Number

55. Complainant's Signature

    Please type name in box provided

56. Date
    Date

Leave This Blank:


57. 1. Receive an email copy of this form.
58. Email address

    This field is not part of the form submission.

59. Submit Submit and Print

* indicates a required field