Title VI Complaint Form
Title VI Complaint Form
The purpose of this form is to assist you in filing a complaint with the Missouri Department of Transportation’s External Civil Rights Division. You are not required to use this form; a letter with the same information is sufficient. However, the information requested in the items marked with a star (*) must be provided, whether or not the form is used.
1.* State your name and address.
Name:
Address:
Zip Code
Telephone No: Home/Cell: ______________________ Work: _____________________
2.* Person(s) discriminated against, if different from above:
Name:
Address:
Zip
Telephone No: Home/Cell: ______________________ Work: _____________________
3.* Agency, department, program, or individual you believe discriminated against you:
Name:
Address:
Zip
Telephone Number: ____________________________
4A.* Non-employment: Does your complaint concern discrimination in the delivery of services or in other discriminatory actions of the department, agency, or individual in its treatment of you or others? If so, please indicate below the base(s) on which you believe these discriminatory actions were taken (e.g., "Race: African American" or "Sex: Female").
___ Race/Color:
___ National origin:
___ Sex:
___ Religion:
___ Age:
___ Disability:
___ Low Income:
___ Familial Status:
4B.* Employment: Does your complaint concern discrimination in employment by the department, agency, or individual? If so, please indicate below the base(s) on which you believe these discriminatory actions were taken (e.g., "Race: African American" or "Sex: Female").
___ Race/Color:
___ National origin:
___ Sex:
___ Religion:
___ Age:
___ Disability:
___ Low Income:
___ Familial Status:
5. What would be the most convenient time and place for us to contact you about this complaint?___________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
6. If we will not be able to reach you directly, can you provide us the name and phone number of a person who can tell us how to reach you and/or provide information about your complaint:
7. If you have an attorney representing you concerning the matters addressed in this complaint, please provide the following:
Name:
Address:
Zip
Telephone Number: ___________________________________
8.* What is the date(s) of the most recent allegation discrimination?
Earliest date of discrimination:
Most recent date of discrimination:
9. Complaints of discrimination must generally be filed within 180 days of the alleged discrimination. If the most recent date of discrimination, listed above, is more than 180 days, you may request a waiver of the filing requirement. If you wish to request a waiver, please explain why you waited until now to file your complaint.
10.* Please explain as clearly as possible what happened, why you believe it happened, and how you were discriminated against. Please use additional sheets if necessary and attach a copy of written materials pertaining to your case.
11. The laws we enforce prohibit recipients of federal funds from intimidating or retaliating against anyone because he or she has either taken action or participated in action to secure rights protected by these laws. If you believe that you have been retaliated against (separate from the discrimination alleged in #10), please explain the circumstances below. Be sure to explain what actions you took which you believe were the basis for the alleged retaliation.
12. Please list below any persons (witnesses, fellow employees, supervisors, or others), if known, whom we may contact for additional information to support or clarify your complaint.
|
Name |
Address |
Area Code/Telephone Numbers |
|
| ________________________ | _______________________________________ |
W:( )__________________ |
(H):( )________________ |
| ________________________ | _______________________________________ |
W:( )__________________ |
(H):( )________________ |
| ________________________ | _______________________________________ |
W:( )__________________ |
(H):( )________________ |
| ________________________ | _______________________________________ |
W:( )__________________ |
(H):( )________________ |
| ________________________ | _______________________________________ |
W:( )__________________ |
(H):( )________________ |
| ________________________ | _______________________________________ |
W:( )__________________ |
(H):( )________________ |
| ________________________ | _______________________________________ |
W:( )__________________ |
(H):( )________________ |
| ________________________ | _______________________________________ |
W:( )__________________ |
(H):( )_________________ |
13. Do you have any other information that you think is relevant to our investigation of your allegations?
14. What remedy are you seeking for the alleged discrimination?
15. Have you (or the person discriminated against) filed the same or any other complaints with other agency? If so, what agency?
Yes____ No ___
16. Have you filed or do you intend to file a charge or complaint concerning the matters raised in this complaint with any of the following?
___ U.S. Equal Employment Opportunity Commission
___ Federal or State Court
___Your State or local Human Relations/Rights Commission
___ Grievance or complaint office
17. If you have already filed a charge or complaint with an agency indicated in #16, above, please provide the following information (attach additional pages if necessary):
Agency:
Date filed:
Location of Agency/Court:
Name of Investigator:
Status of Case:
18.* We cannot accept a complaint if it has not been signed. Please sign and date your complaint form.
____________________ ________________________________________
(Date) (Signature)
Please feel free to add additional sheets to explain the present situation to us.
We will need your consent to disclose your name, if necessary, in the course of any investigation. We will send a Consent Form to you after receiving your complaint. (If you are filing this complaint for a person whom you allege has been discriminated against, we will in most instances need a signed Consent Form from that person.). Please mail the completed, signed Discrimination Complaint Form (please make a copy for your records) to:
Missouri Department of Transportation
External Civil Rights Division
1617 Missouri Blvd
PO Box 270
Jefferson City, MO 65102
573-751-2859
Relay Missouri 1.800.735.2966
7.1.1 (Toll-Free TTY)