Title VI/ADA Complaint Form Note: The following information is needed to assist in processing your complaint.
Complainant's information
Name: _____________________________________________________________ Address: ___________________________________________________________ City/State/Zip Code: __________________________________________________ Telephone Number (Home): ____________________________________________ Telephone Number (Other): ____________________________________________ Person discriminated against (if someone other than complainant): Name: _____________________________________________________________ Address: ___________________________________________________________ City/State/Zip Code: __________________________________________________ Telephone Number (Home): ____________________________________________ Telephone Number (Other): ____________________________________________ Email Address: ______________________________________________________
Relationship to the person for whom you are complaining
Please explain why you have filed for a third party
Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party. O Yes O No
Which of the following best describes the reason you believe the discrimination took place? Please Circle. Race Color National Origin Disability
Other
On what date(s} did the alleged discrimination take place?
Date
Date
Date
Please describe the alleged discrimination. Explain what happened and whom you believe was responsible. 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. Include the location(s) of the alleged act of discrimination (include vehicle number if appropriate). If additional space is needed, add a sheet of paper. Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? Circle all that apply. State Agency Federal Agency State Court Federal Court Local Agency If you have checked above, please provide information about a contact person at the agency/court where the complaint was filed. Name: ______________________________________________________________ Address: ____________________________________________________________ City/State/Zip Code: ___________________________________________________ Telephone Number (Home): ____________________________________________ Telephone Number (Other): ____________________________________________ Email Address: _______________________________________________________ Please sign below. You may attach any written materials or other information that you think is relevant to your complaint.
Signature
Attachments: Yes No ___________________________________________________________ Date: _______________________________________________________________
Submit form and any additional information to
Diane R. Taylor, Director of Human Resources Senior Services of Southeastern Virginia 2551 Eltham Ave Suite Q, Norfolk, Virginia 23513 or email dtaylor@ssseva.org