Title VI & Civil Rights Complaint Form

First

Last

Phone

Home Address:

Address

City/Town

State/Province

ZIP/Postal Code

Discrimination Complaint

Name of Staff Person that you Believe Discriminated Against You

First

Last

Date of Alleged Incident

You were discriminated against because of?

Color

National Origin

Race

Age

Disability

Sex

Explain as briefly and clearly as possible what happened and how you were discriminated against. Indicate who was involved. Be sure to include how other persons were treated differently than you. Also attach any written material pertaining to your case such as any persons (witnesses, fellow employees, supervisors, or others), if known, whom we may contact for additional information to support or clarify your complaint. (Please be sure to provide contact information, and use additional sheets if necessary.)

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