Title VI Non-Discrimination Complaint Form Title VI Non-Discrimination Complaint Form If you are human, leave this field blank. Check what you believe to be the basis for the discrimination against you, such as race, sex or national origin. If you think that was more than one basis, more than one basis may be checked. You may also check more than one race/ethnic category. I believe I was (or continue to be discriminated against because of the following basis): * Race Color Religion Sex National Origin Hispanic or Latino American Indian or Alaska Native Black or African American Native Hawaiian or Other Pacific Islander Asian White OtherOther Have you filed a complaint with any other agency? * Yes No If yes, please list the name of the agency or agencies If yes, please list the name(s) of department employees or programs/offices involved in discrimination and/or harassment (if known): Please list the name(s) of department employees or programs/offices involved in discrimination and/or harassment (if known): * Name(s) of any witnesses: * Explain Specific Complaint: * (Explain what happened, the date(s) incidents occurred, who was involved etc.) First Name * Last Name * Address * Address Address Address City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Phone * Email * All complaints need to be filed within 180 days of the last occurrence of discrimination and/or harassment. Signature * Clear Submit
