Fillable TITLE VI DISCRIMINATION COMPLAINT FORM (County of San Diego)

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TITLE VI DISCRIMINATION COMPLAINT FORM (County of San Diego)

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Pursuant to the Federal ivacy Act .L Inform
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COUNTY OF SAN DIEGO
OFFICE OF ETHICS AND COMPLIANCE
TITLE VI DISCRIMINATION COMPLAINT FORM
Title VI of the Civil Rights Act of 1964, as amended, and related statutes prohibit
discrimination by the County of San Diego on the basis of race, color, national origin,
sex, age, or disability in connection with programs or activities receiving federal financial
assistance.
Additionally, pursuant to Executive Order 13166 and the Americans with Disabilities Act
of 1990, the County is required to implement measures to ensure that persons with
limited English proficiency and persons with disabilities have meaningful access to the
services, benefits, and information of all of the County’s programs and activities.
If you believe that you have been discriminated against by the County in the provision of
services based on your race, color, national origin, sex, age, or disability, you may file a
complaint on the attached Title VI Discrimination Complaint Form. Complaints must be
filed within one hundred-eighty (180) calendar days after you believe the discrimination
occurred.
Upon request, assistance with completing the form will be provided if you have limited
English proficiency or a disability. Complaints may also be filed using alternate formats
such as computer disk, audiotape, or in Braille. For TTY customers, dial 711 to reach
the California Relay Service. You will be asked to give the telephone number you are
calling.
The County and its subrecipients, consultants, and contractors, irrespective of tier, are
prohibited from retaliating against any individual because he or she opposed an
unlawful policy or practice, or made charges, testified, or participated in any complaint
action under Title VI, the Civil Rights Restoration Act of 1987, or other nondiscrimination
authorities.
Please complete and return this form to:
Title VI Coordinator
Office of Ethics and Compliance
1600 Pacific Highway, Room 400
San Diego, California 92101-2472
Telephone: (619) 531-5174
TTY: 711
Personal Information Notice
Pursuant to the Federal Privacy Act (P.L. 93-579) and the Information Practices Act of 1977 (Civil Code Section 1798, et
seq.) notice is hereby given for the request of personal information by this form. The requested personal information is
voluntary. The principle purpose of the voluntary information is to facilitate the processing of this form. The failure to
provide all or any part of the collected information may impact our ability to investigate your complaint and may delay
processing of this form. No disclosure of personal information will be made unless permissible under applicable law.
Each individual has the right upon request and proper identification to inspect all personal information maintained on the
individual by an identifying particular.
Revised 5/12/17
COUNTY OF SAN DIEGO
OFFICE OF ETHICS AND COMPLIANCE
TITLE VI DISCRIMINATION COMPLAINT FORM
Date:
Complainant’s Name: ____________________________________________________
Mailing Address:
City: _ _State: ______ Zip Code:
Home Telephone: ( ) _ Alternate Telephone: ( )
Email: ________________________________________________________________
Which of these best describes the reason you feel you were discriminated against:
O
Race
O
Age
O
Color
O
Sex
O
National Origin
O
Disability
When and where did the alleged discrimination take place?
In your own words, describe the alleged discrimination. Explain what happened, how
you were treated differently from others, and whom you believe to be responsible.
Please be as specific as possible and use additional sheets of paper if necessary:
Page 1 of 2
Name(s) of individual(s) responsible for the alleged discriminatory action(s):
List any others who may have witnessed this event:
Name Address City/State/Zip Phone
If you have filed a complaint about the same alleged discriminatory event with any of the
following entities, please identify the entity and give the date of filing. Please note that if
you filed a complaint with any of these other agencies, the Office of Ethics and
Compliance is precluded from accepting and investigating your complaint. This applies
to any complaint that you initially filed with the Office of Ethics and Compliance and
which you later file with an external agency.
O Equal Employment Opportunity Commission (EEOC)
O Department of Fair Employment and Housing (DFEH)
O Office of Civil Rights (OCR)
O U.S. Department of Justice
O California Attorney General
O Federal Court
O State Court
O Other Federal Agency (List)
O Other State Agency (List)
Signature of Complainant: Date:
Page 2 of 2
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TITLE VI DISCRIMINATION COMPLAINT FORM (County of San Diego)

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Completed 18 July 2020

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