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Title VI Non-Discrimination Complaint Form

Title VI Non-Discrimination Complaint Form

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): *
Have you filed a complaint with any other agency? *
(Explain what happened, the date(s) incidents occurred, who was involved etc.)
Address *
Address
City
State/Province
Zip/Postal

All complaints need to be filed within 180 days of the last occurrence of discrimination and/or harassment.