Fillable City of Woodburn Title VI and ADA Title (City of Woodburn)

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City of Woodburn Title VI and ADA Title (City of Woodburn)

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The City of Woodburn Title VI and ADA Title (City of Woodburn) form is 2 pages long and contains:

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  • 12 check-boxes
  • 31 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of Woodburn

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City of Woodburn Title VI and ADA Title II Complaint Form
Zip Code:
Name:
Address:
City:
State:
Telephone Number:
You felt you were discriminated against because of your:
Race/Ethnicity National Origin Gender
Religion Age Disability
Other:
To your best recollection, date and time of alleged incident:
In your own words, please describe the alleged discrimination. Explain what happened and what
policy, program, activity or person you believe was discriminatory. Indicate who was involved
and if applicable, the transit route and vehicle. Be sure to include the names and contact
information of any witnesses. If more space is needed, please use additional pages.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Have you already tried to resolve the issue through a grievance process or some other method?
Yes No
______________________________________________________________________________
______________________________________________________________________________
HR-ADA/07 ADA Complaint Form Revised 2/2017
What type of corrective action or resolution would you like to see taken?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Have you filed this complaint with any other federal, state or local agency or with any court?
Yes No
If yes, check and identify all that apply:
Federal Agency ________________________
Federal Court ________________________
State Agency ________________________
State Court ________________________
Local Agency ________________________
Please provide information for a contact person at the Agency or Court where the complaint was
filed.
Name: __________________________________________________________________
Address: ________________________________________________________________
City, State, & Zip Code: ___________________________________________________
Telephone Number: _______________________________________________________
Please sign below (we cannot accept unsigned complaints). You may attach any additional written
materials or other information you believe is relevant to your complaint.
Signature Date
Pl
ease mail this form to:
Human Resources Director
City of Woodburn
270 Montgomery St
Woodburn, OR 97071
HR-ADA/07 ADA Complaint Form Revised 2/2017
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City of Woodburn Title VI and ADA Title (City of Woodburn)

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Completed 17 July 2020

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