Fillable External Title VI Discrimination Complaint Form travis county

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External Title VI Discrimination Complaint Form travis county

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Effective 8/2014
External Title VI Discrimination Complaint Form
Mail the completed and signed form to: Title VI Coordinator, 700 Lavaca, Austin, Texas 78701
Last Name First Name
Mailing Address
City State Zip
Telephone Email Address
Race: Color:
Ethnicity/National Origin: Sex:
Please indicate the basis of your complaint:
Date and place of alleged discriminatory action (s). Please include the earliest date of
discrimination and the most 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).
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
The law prohibits intimidation or retaliation against anyone because he/she has either taken
action, or participated 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.
Names of individuals responsible for the discriminatory action(s):
______________________________________________________________________________
Effective 8/2014
______________________________________________________________________________
____________________________________________________________________________
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
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Have you filed, or intend to file, a complaint regarding the matter raised with any of the
following? If yes, please provide the filing dates. Check all that apply.
_____ U.S. Department of Transportation_________________________________________
_____ Federal Highway Administration___________________________________________
_____ Federal Transit Administration_____________________________________________
_____ Office of Federal Contract Compliance Programs______________________________
_____ U.S. Equal Employment Opportunity Commission (EEOC)______________________
_____ U.S. Department of Justice______________
_____ Other: ________________________________________________________________
Have you discussed the complaint with any Travis County representative? If yes, provide the
name, position, and date of discussion.
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________
Briefly explain what remedy, or action, you are seeking for the alleged discrimination.
______________________________________________________________________________
_____________________________________________________________________________
Please provide any additional information and/or photographs, if applicable, that you believe will
assist with an 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: __________________ Case#: ________________
Processed by: ____________________________ Date Referred: __________
Referred to: _ USDOT _FHWA _FTA _OFCCP _EEOC _OTHER ______
_____________________________________________________________________________
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External Title VI Discrimination Complaint Form travis county

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Completed 18 January 2020

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