CONTACT INFORMATION
Name: ___________________________________________________________________________________________
Address: _________________________________________________________________________________________
Phone: ___________________________________________ Email: __________________________________________
COMPLAINT DETAILS
Date of Incident: __________________________________________________________________________________
Department/Agency: _______________________________________________________________________________
Location or Address: _______________________________________________________________________________
Language Access Issue: (check all that apply)
Lack of signs informing the public for translation services in Spanish and Chinese
Lack of forms/materials in Spanish/Chinese Lack of bilingual personnel Other
What language did you need assistance with?___________________________________________________________
Brief Description: (attach additional pages if needed) _____________________________________________________
__________________________________________________________________________________________________
FORM ASSITANCE
Did someone assist you in completing this form?
Yes " No
Name: ____________________________________________________________________________________________
Organization: _____________________________________________________________________________________
Phone: ___________________________________________ Email: __________________________________________
DEPARTMENT USE ONLY
Date Received:
Action Taken:
Contact Person:
Phone:
Email:
Please return this form to: EQUAL ACCESS OFFICE
Department of Human Resources Management, 150 Frank H. Ogawa Plaza 2nd Floor, Oakland, CA 94612
You can also fax it to (510) 238-2325. If you have any questions please call (510) 238-3112.
LANGUAGE ACCESS COMPLAINT FORM
The purpose of this form is to record complaints related to language access to City services.