Fillable 8965bb06-f83a-4a5d-ab94-325613134369 Title Six Discrimination Complaint Form

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8965bb06-f83a-4a5d-ab94-325613134369 Title Six Discrimination Complaint Form

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The 8965bb06-f83a-4a5d-ab94-325613134369 Title Six Discrimination Complaint Form form is 2 pages long and contains:

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  • 25 check-boxes
  • 45 other fields

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File type: PDF

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TITLE VI DISCRIMINATION COMPLAINT FORM
Mail, Fax, or Email this signed form to:
City of Fort Worth Human Relations Department
200 Texas Street
Fort Worth, Texas 76102
(817) 392-7525 Fax: (817) 392-7529
Email: FWHRC@fortworthtexas.gov
Last Name
First Name
Mailing Address
City
State
ZIP
Telephone
Alternative Telephone
Email Address
Race
Age
National Origin
Color
Sex
Disability
Income Status
Limited English Proficiency
Creed
recent date of discrimination
How were you discriminated against? Describe the nature of the action, decision, or conditions of the alleged
discrimination. Explain as clearly as possible what happened and why you believe your protected status (basis) was
a factor in the discrimination. Include how other persons were treated differently from you. (Attach additional pages,
if necessary)
in action, to secure rights protected by these laws. If you feel that you have been retaliated against, separate from
the discrimination alleged above, please explain the circumstances below. Explain what action you took which you
believe was the cause for the alleged retaliation. (Attach additional pages, if necessary)
Include the name, address, and phone number of the individual(s) or organization you believe is responsible for the
discriminatory action)
Names of persons (witnesses, fellow employees, supervisors, or others) whom we may contact for additional
information to support or clarify your complaint: (Attach additional pages, if necessary)
Name
Address
Telephone
1.
2.
3.
4.
Have you filed, or intend to file, a complaint, regarding the matter raised with any of the following agencies? If
yes, please provide the filing dates. Check all that apply:
U. S. Department of Transportation
Federal Highway Administration
Federal Transit Administration
Federal Aviation Administration
Office of Federal; Contract Compliance Programs
U.S. Equal Employment Opportunity Commission
U.S. Department of Justice
Other:
dates(s) of discussion.
investigation.
We cannot accept an unsigned complaint. Please sign and date the complaint form below.
Complainant’s Signature Date
FOR OFFICE USE ONLY
Date Complaint Received: Processed By:
Case #:
Referred To: Date Referred:
USDOT FHWA FTA FAA
OFCCP US EEOC USDOJ Other
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8965bb06-f83a-4a5d-ab94-325613134369 Title Six Discrimination Complaint Form

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Completed 12 July 2020

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