Fillable COVERED CALIFORNIA BILINGUAL SERVICES COMPLAINT FORM (Covered California)

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COVERED CALIFORNIA BILINGUAL SERVICES COMPLAINT FORM (Covered California)

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COVERED CALIFORNIA
BILINGUAL SERVICES COMPLAINT FORM
The Dymally-Alatorre Bilingual Services Act (Act) became law in 1973 to ensure that
individuals whose primary language is not English are not precluded from utilizing public
information and services because of language barriers. This form is provided for people
who wish to file a complaint about bilingual services received at Covered California.
GENERAL INSTRUCTIONS: Please provide the following information in the sections
below so that your complaint may be appropriately addressed. Should you have any
questions or need to request assistance in completing this form, please contact the
Covered California Equal Employment Opportunity Office at (916) 228-8268.
Complainant’s Name:___________________________________________________
Address:
____________________________________________________________________
City: __________________________State: ____________ Zip Code: ____________
Telephone No. (Home): ___________________(Business): ______________________
Telephone No. (Cell):_____________________ E-mail address: __________________
Name of person who allegedly received inadequate bilingual services (if other than
complainant):
______________________________________________________________________
Address:
______________________________________________________________________
City: __________________________ State: _____________Zip Code: _____________
Telephone No. (Home): __________________ (Business): ______________________
Telephone No. (Cell):___________________ E-mail address: ___________________
Date of incident: ___________________________________
Page 2 of 4
Describe the circumstances surrounding the bilingual services received. Be specific
about what happened, when it occurred, who was involved, etc. (Attach additional
sheets of paper as needed.)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
What Covered California employee(s) does the complainant allege were involved?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Where did the incident take place?
______________________________________________________________________
If not English, what is complainant’s primary language?
______________________________________________________________________
Were there witnesses? If yes, please provide their contact information below:
Name:
______________________________________________________________________
Address:
______________________________________________________________________
City: ____________________________ State: __________Zip Code: ______________
Telephone Numbers: (Home) ___________________ (Business): _________________
Page 3 of 4
Name:
______________________________________________________________________
Address:
______________________________________________________________________
City: __________________________ State: _________ Zip Code: ________________
Telephone Numbers: (Home) __________________ (Business): __________________
How could Covered California improve its bilingual services?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Complainant: Please sign and date in the spaces below.
__________________________________________ ___________________
Complainant’s Signature Date
Attach supporting documents to this complaint form. This form can be saved to your
desktop and then attached to an email. You may also submit this complaint form and
supporting documentation in person, by mail, or facsimile transmission (fax) to:
Covered California
ATTN: EEO OFFICER
1601 Exposition Blvd.
Sacramento, CA 95815
FAX: (916) 228-8909
EMAIL: EEO@covered.ca.gov
Page 4 of 4
For official use only:
Complaint received by (name):
___________________________________________________
Date: ___________________
Action Taken:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Form updated 08/2016
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COVERED CALIFORNIA BILINGUAL SERVICES COMPLAINT FORM (Covered California)

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Completed 19 May 2021

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