Title VI and ADA Complaint Form

GoochlandCares

Title VI and ADA (Non-Discrimination) Complaint Form

CLICK HERE for Title VI and ADA (Non-Discrimination) Complaint Form in PDF format.

 

Section I

 

Name: _________________________________________________________

Date of Complaint:  ________________________________________________

Address:  _______________________________________________________

Home Phone:  _______________________ 

Other Phone:  ________________________

Email:  ________________________________________________________

Accessible Format Requirements (check all that apply)

               Large Print                    Audio Tape                     TDD                    Other

Section II

Are you filing this complaint on your own behalf?   ___ yes*           ___ no

*If yes, go to Section III

If, no, please share the name and relationship of the person for whom you are complaining:

Name:  _______________________________________________________

Relationship:  ___________________________________________________

Reason you are complaining on behalf of this person (why are they not completing the form themselves):

_______________________________________________________________

_______________________________________________________________

Do you have the permission of the aggrieved party to file on their behalf?  ___ yes    ___ no

 

Section III

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

______Race     ______Color     _____National Origin     ____Disability

Date of Alleged Discrimination (Month, Date, Year):  ___________________________

Explain as clearly as possible what happened and why you believe you were discriminated against.  Describe all persons who were involved.  Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses.  If more space is needed, please use the back of this form.

                                                                                                                                                

                                                                                                                                                

                                                                                                                                                

                                                                                                                                                 

 

Section IV

Have you previously filed a Title VI complaint with this agency?     ___ yes     ___ no

 

Section V

Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court?     ___ yes     ___ no

If yes, circle all that apply.

Federal Agency       Federal Court          State Agency          State Court          Local Agency

Please provide information about a contact person at the agency/court where the complaint was filed.

Name	Title	Agency	Address	Phone

 

Section VI

Name of Agency complaint is about:  ____________________________

Contact Person:  __________________________________________

Title:  _________________________________________________

Phone Number:  __________________________________________

Email:  _________________________________________________

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

 

Signature (required)                                                     Date (required)

Submit this form in person or mail to the address below:

Alison Smith, Director of Finance
2999 River Road West
Goochland, VA 23063
asmith@goochlandcares.org
804-556-6260

CLICK HERE for Title VI and ADA (Non-Discrimination) Complaint Form in PDF format.