CCRSI Title VI Complaint Form

7. I believe that the discrimination I experienced was based on (check all that apply):

Race (Class Protected by Title VI)Color (Class Protected by Title VI)National Origin (Class Protected by Title VI)Disability (Class Protected by ADA)Other
8. Date of Alleged Discrimination:

MonthDayYear
9. Where did the Alleged Discrimination take place?
10. Explain as clearly as possible what happened and why you believe that you were discriminated against. Describe all of the persons that were involved. Include the name and contact information of the person(s) who discriminated against you (if known). If necessary upload additional pages below.
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11. Please list any and all witnesses' names and phone numbers/contact information. If necessary upload additional pages below.
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12. What type of corrective action would you like to see taken?

13. Have you filed a complaint with any other federal, state, or local agency; or with any federal or state court?

YesNo
If "YES", check all that apply:

Federal Agency (specify agency)State Agency (specify agency)Local Agency (specify agency)Federal Court (specify location)State CourtCounty Court (specify Court and County)
Specify the Agency and/or Court information that is referenced above:
14: If "YES" to Question 13 above, please provide information about a contact person at the agency/court where the complaint was filed. (Attach additional information below if necessary.)
Full Name

First NameLast Name
Title:
Agency:
Phone Number:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
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You may attach any written materials or other information that you think is relevant to your complaint.

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