DEPARTMENT OF CHILD SUPPORT SERVICES
LANGUAGE ACCESS COMPLAINT FORM
Use this form to record complaints related to language access with the California Department of Child Support
Services. Please return this form and any related documentation to the Equal Employment Opportunity Office,
Fax #: 916.464.0199; email: personnelhelp@dcss.ca.gov
; or mail to: Department of Child Support Services, Equal
Employment Opportunity Office, P.O. Box 419064, Rancho Cordova, CA 95741-9064.
1. CONTACT INFORMATION
Name:
Address:
Phone Number:
Email:
2. COMPLAINT DETAILS
Date of Incident:
Department/Agency:
Location or Address:
Language Access Issue(s):
(Check all that apply)
Lack of forms/materials in the language I needed
Lack of bilingual personnel
I was not offered an interpreter
Other: (please specify below)____________________________________________
What language did you
need assistance with?
Spanish Mandarin Russian Cantonese
Tagalog Vietnamese Other: ____________________
Brief Description: Please be specific. Attach additional pages if necessary.
3. FORM ASSISTANCE
Did someone assist you in completing this form?
Yes (input information below)
No (leave blank below)
Name:
Organization:
Phone Number:
Email:
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
DO NOT WRITE IN THIS BOX (DEPARTMENTAL USE ONLY).
Date Received:
Action Taken:
Contact Person:
Phone:
Email:
.
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