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Title VI Complaint Form

  1. Complainant Information

  2. Incident Information

  3. Please detail incident report in the section below.

  4. Please provide the location of incident.

  5. Type of Discrimination *

    Please check all options that are applicable to your incident.

  6. If you choose Other Protected Status please list that discrimination

  7. Please detail the incident

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

  9. Please put witness name and best number to contact this person

  10. Please put witness name and best number to contact this person

  11. Please put witness name and best number to contact this person

  12. 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.

  13. Please type name in box provided

  14. Leave This Blank:

  15. This field is not part of the form submission.