TITLE VI PROGRAM

 

FOR FENTRESS COUNTY,

TENNESSEE

 

PRESENTED DURING THE

REGULAR SESSION OF THE

FENTRESS COUNTY BOARD

OF COMMISSION MEETING

ON OCTOBER 20, 2008

 

REVISED September 11, 2013

November 13, 2014, September 5, 2018

 

 

 

Title VI PROGRAM PRESENTED FOR APPROVAL

INCLUDES THE FOLLOWING

 

 

·         RESOLUTION TO AFFIRM COMPLIANCE                                              3

 

·         LEGISLATIVE HISTORY AND PURPOSE OF TITLE VI                        4

 

·         APPOINTMENT OF CERTIFIED TITLE VI COORDINATOR                9

 

·         TITLE VI PUBLIC NOTICE                                                                         10

 

·         FENTRESS COUNTY TITLE VI POLICY                                                11

 

·         EQUAL OPPORTUNITY TITLE VI POLICY STATEMENT                   12

 

·         FENTRESS COUNTY GOVERNMENT TITLE VI

NONDISCRIMINATION STATEMENT                                                     13

 

·         TITLE VI BROCHURES ENGLISH & SPANISH                                    14

 

·         FENTRESS COUNTY GOVERNMENT TITLE VI PROGRAM            18

 

·         LIMITED ENGLISH POLICY AND PROCEDURE                                 20

 

·         LANGUAGE IDENTIFICATION FLASH CARDS                                   21

 

·         CONTRACT WITH OPEN COMMUNICATIONS INTERNATIONAL

INTERPRETING AND TRANSLATING SERVICES                              24

 

·         NEW EMPLOYEE ORIENTATION TITLE VI SHEET                            25

 

·         TITLE VI ACKNOWLEDGEMENT SHEET                                              26

 

·         TITLE VI COMPLAINT PROCEDURE                                                    27

 

 

 

 

 

 

 

Fentress County Government – Title VI

History and Purpose of Title VI

 

The landmark Civil Rights Act of 1964 was a product of the growing demand during the early 1960s for the Federal Government to launch a nationwide offensive against racial discrimination. In calling for its enactment, President John F. Kennedy identified "simple justice" as the justification for Title VI:

Simple justice requires that public funds, to which all taxpayers of all races contribute, not be spent in any fashion which encourages, entrenches, subsidizes, or results in racial discrimination. Direct discrimination by Federal, State, or local governments is prohibited by the Constitution. But indirect discrimination, through the use of Federal funds, is just as invidious; and it should not be necessary to resort to the courts to prevent each individual violation.

Title VI was not the first attempt to ensure that Federal monies not be used to finance discrimination on the basis of race, color, or national origin. For example, various prior Executive Orders prohibited racial discrimination in the armed forces, in employment by federally funded construction contractors, and in federally assisted housing. (2) Various Federal court decisions also served to eliminate discrimination in individual federally assisted programs. (3)

Congress recognized the need for a statutory nondiscrimination provision such as Title VI to apply across-the-board "to make sure that the funds of the United States are not used to support racial discrimination." 110 Cong. Rec. 6544 (Statement of Sen. Humphrey). Senator Humphrey, the Senate manager of H.R. 7152, which became the Civil Rights Act of 1964, identified several reasons for the enactment of Title VI. Id. First, several Federal financial assistance statutes, enacted prior to Brown v. Board of Education, 347 U.S. 483 (1954), expressly provided for Federal grants to racially segregated institutions under the "separate but equal" doctrine that was overturned by Brown. Although the validity of these programs was doubtful after Brown, this decision did not automatically invalidate these statutory provisions. Second, Title VI would eliminate any doubts that some Federal agencies may have had about their authority to prohibit discrimination in their programs.

Third, through Title VI, Congress would "insure the uniformity and permanence to the nondiscrimination policy" in all programs and activities involving Federal financial assistance. Id. Thus, Title VI would eliminate the need for Congress to debate nondiscrimination amendments in each new piece of legislation authorizing Federal financial assistance. (4) As stated by Congressman Celler:

Title VI enables the Congress to consider the overall issue of racial discrimination separately from the issue of the desirability of particular Federal assistance programs. Its enactment would avoid for the future the occasion for further legislative maneuvers like the so-called Powell amendment.

Fourth, the supporters of Title VI considered it an efficient alternative to litigation. It was uncertain whether the courts consistently would declare that government funding to recipients that engaged in discriminatory practices was unconstitutional. Prior court decisions had demonstrated that litigation involving private discrimination would proceed slowly, and the adoption of Title VI was seen as an alternative to such an arduous route. See 110 Cong. Rec. 7054 (1964) (Statement by Sen. Pastore).

Further, despite various remedial efforts, racial discrimination continued to be widely subsidized by Federal funds. For example, Senator Pastore addressed how North Carolina hospitals received substantial Federal monies for construction, that such hospitals discriminated against blacks as patients and as medical staff, and that, in the absence of legislation, judicial action was the only means to end these discriminatory practices.

That is why we need Title VI of the Civil Rights Act, H.R. 7152 - to prevent such discrimination where Federal funds are involved. . . . Title VI is sound; it is morally right; it is legally right; it is constitutionally right. . . . What will it accomplish? It will guarantee that the money collected by colorblind tax collectors will be distributed by Federal and State administrators who are equally colorblind. Let me say it again: The title has a simple purpose - to eliminate discrimination in federally financed programs. 

President Lyndon Johnson signed the Civil Rights Act of 1964 into law on July 2, 1964, after more than a year of hearings, analyses, and debate. During the course of congressional consideration, Title VI was one of the most debated provisions of the Act.

 

******************

 

 

Source: Title VI Legal Manual                                                                                                            Department of Justice

 

 

 

 

 

 

 

 

 

Title VI

 

What is Title VI?

 

Title VI prohibits discrimination on the basis of race, color, or national origin in programs and activities receiving Federal financial assistance. Specifically, Title VI provides that

No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.

How does Title VI affect my county, city, community or business?

 

State agencies, local or municipal government entities, educational institutions, for profit and non-profit corporations and institutions that receive federal financial assistance are subject to Title VI of the Civil Rights Act of 1964 and the Civil Rights Restoration Act of 1987. According to the Tennessee Attorney General, state and local governmental agencies that administer federally funded programs are required to comply with Title VI of the Civil Rights act and all applicable federal regulations. The Attorney General concluded that under certain circumstances federal authorities may refuse to grant or continue federal financial assistance for failure to comply with Title VI and its regulations. Therefore, all state and local agencies in Tennessee which administer federally funded programs are advised to use their best efforts in complying with Title VI and all other federal regulations applicable to the administration of such programs.

 

Policy Statement

 

Fentress County Government will comply with the Title VI Civil Rights Act of 1964 and the Civil Rights Restoration Act of 1987. The department will utilize its best efforts in maintaining compliance in all programs subject to the requirements of Title VI and all other federal regulations applicable to the administration of such programs.

 

Fentress County Government:

• will not deny any person service, assistance or other benefits for which you are qualified;

 

•will not provide any person with a service different from that provided to others under the same program;

 

• will not subject any person to separate treatment in any manner related to services, aid or other benefits;

 

•will not limit any person in anyway in the use of services, facilities, or any other advantages, privileges, or benefits provided to others under any program;

•will not treat any person differently from others in deciding whether you meet requirements to receive aid, care, service or other benefit;

 

• will not deny any person or offer an opportunity different from that offered others in any program or service;

 

•will not adopt methods that limit participation by any group of recipients or subject them to discrimination; and

 

•will not refer any person to agencies that do not obey civil rights law.

 

 

All agencies receiving financial assistance through the department must sign a statement of compliance with Title VI of the Civil Rights Act of 1964.

 

Complaints of Discrimination

 

A complaint alleging discrimination may be filed with the Title VI Coordinator. All entities receiving assistance from the department will be required to have information available for public review on the procedures for filing a complaint.

 

The Title VI Coordinator has the responsibility for receiving, logging, acknowledging, investigating complaints and reporting the findings. The coordinator will notify the commissioner and the appropriate program director when a complaint is received.

 

After receiving a complaint or identifying potential discriminating activity the department will take the following steps:

•Within 30 calendar days of receiving the complaint, the Title VI Coordinator will conduct a fact finding investigation. The coordinator will meet with the complainant or the staff member who identified the alleged discriminatory activity to determine the nature of the complaint and whether Title VI requirements were violated. The coordinator will meet with the director in whose area the alleged violation occurred to ascertain the director’s perspective on the complaint. The coordinator will notify the members of the Title VI Review Committee

 

•If the coordinator determines that discrimination has not occurred, the complainant, commissioner, and program director will be informed. The complainant will then have a right to appeal the decision.

 

• If the investigation indicates that discrimination did in fact occur, it will be discussed with the program director. The Title VI Coordinator will discuss ways in which to resolve the complaint and seek voluntary corrective action.

 

•The complainant, applicant, or program director may appeal any rulings made by the coordinator to the Title VI Review Committee within 10 calendar days of the receipt of the written findings. The request can include relevant documentation and sworn testimony, if any, from appealing party together with any testimony by witnesses having first-hand knowledge of the Title VI violations. The testimony may be in the form of an affidavit and shall describe in detail the circumstances and events which would lead a reasonable person to believe that a Title VI violation has occurred. The Title VI Review Committee will have broad latitude to review an appealed case and make a finding. The committee may discuss the complaint with the complainant, the alleged offender, the Title VI Coordinator, or other parties to determine the facts. The committee will make a finding on the appeal within 15 calendar days of receipt of the request for appeal.

 

• If the discriminatory activity cannot be resolved by the committee, a written report on the situation will be prepared and forwarded to the Tennessee Title VI Compliance Commission. If a complaint involves one of the department’s federally funded programs, the federal agency sponsoring the program will also be notified. Information will also be provided to the parties involved on the procedures for appealing to the federal level.

 

• If either the Tennessee Title VI Compliance Commission, or other federal agency determines that discrimination has in fact occurred, the offending party will be denied further services or benefits of the department’s programs until the discriminatory activities have been terminated.

 

Complaints may be filed with:

 

Fentress County Government

Becky Crockett

Title VI Coordinator

P. O. Box 1128

Jamestown, TN 38556

Telephone: 931-879-3010

E-Mail: Becky.Crockett@FentressCountyTn.gov

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PUBLIC NOTICE

 

 

 

TITLE VI OF THE 1964 CIVIL RIGHTS ACT

 

 

 

“No person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.”

 

 

The State Department of Military provides benefits and services such as emergency management assistance, National Guard protection services and facility construction and maintenance, and disaster assistance following a major Presidential declaration.  The federal assistance administered by the Military Department are pass through funds to local governments, other state agencies, and certain private non-profit organizations.

 

 

Anyone who believes that an agency or local government receiving the federal funding mentioned above has discriminated against someone on the basis of race, color or national origin has a right to file a complaint within 180 days of the alleged discrimination.

 

 

 

 

 

 

 

 

 

 

 

 

 

FENTRESS COUNTY GOVERNMENT TITLE VI POLICY

 

  1.

No person shall, on the grounds of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.

  2.

This policy applies to all activities of any department of Fentress County Government.

  3.

The Administrative Assistant has been designated by the Fentress County Executive to serve as the Title VI Coordinator whose primary responsibility is to facilitate Title VI matters.

  4.

Title VI Coordinator will maintain permanent records, submit required Title VI reports, complete all Title VI self-surveys and attend necessary training(s).

  5.

Title VI information posters, including the name of the Title VI Coordinator and contact information, shall be prominently and publicly displayed in each department.

  6.

Title VI information shall be disseminated to county employees at least once per year via payroll stuffers. This brochure of information reminds the employees of the county’s policy statement, and of their Title VI responsibilities in their daily work and duties.

  7.

During new employee orientation, new employees shall be informed of the provisions of Title VI and the county’s expectations to perform their duties accordingly. Necessary information shall be distributed to the new employee by the Title VI Coordinator.

  8.

Title VI information shall be disseminated to citizens at least once per year by public service announcement through the newspaper, internet website or local broadcast media.

  9.

Whenever possible, Fentress County will take positive and specific actions to advise minorities of program availability by using such means of communication as newspaper, public area postings and local cable broadcast.

10.

All subcontractors and vendors who receive payments from Fentress County Government where funding originates from any federal assistance received by the involved department are subject to provisions of Title VI of the Civil Rights Act of 1964 as amended.

11.

Written Contracts shall contain nondiscrimination language, either directly or through the bid specification package which becomes an associated component of the contract

12.

County facilities (such as restrooms, roads, park facilities, etc.) which are accessible to citizens shall be accessible without regard to race, color, or national origin.

13

County employees shall use courtesy titles (i.e. Mr., Mrs., Ms., or Miss) to address citizens without regard to race, color or national origin.

 

 

 

 

 

 

 

FENTRESS COUNTY GOVERNMENT

TITLE VI NON-DISCRIMINATION STATEMENT

 

 

 

FENTRESS COUNTY ENSURES COMPLIANCE WITH THE TITLE VI OF THE CIVIL RIGHTS ACT OF 1964; 49 CFR, PART 21; RELATED STATUES AND REGULATIONS TO THE END THAT NO PERSON SHALL BE EXCLUDED FROM PARTICIPATION IN OR BE DENIED THE BENEFITS OF, OR BE SUBJECTED TO DISCRIMINATION UNDER ANY PROGRAM OR ACTIVITY RECEIVING FEDERAL FINANCIAL ASSISTANCE FROM THE U.S. DEPARTMENT OF TRANSPORTATION ON THE GROUNDS OF RACE, COLOR, SEX, OR NATIONAL ORGIN.

 

ANY PERSON WHO BELIEVES HE OR SHE HAS BEEN DISCRIMINATED AGAINST SHOULD CONTACT THE FENTRESS COUNTY TITLE VI COORDINATOR:

 

FENTRESS COUNTY GOVERNMENT

AMANDA HICKS

TITLE VI COORDINATOR

P.O. BOX 1128

JAMESTOWN, TN  38556

TELEPHONE:  931-879-7713

 

 

 

 

I ACKNOWLEDGE RECEIPT OF TITLE VI NOTICE AND ITS REQUIREMENTS ALONG WITH THE TITLE VI BROCHURE.

 

 

 

 

 

 

            SIGNATURE                                                                                           DATE

 

 

 

 

 

 

 

 

 

 

 

LIMITED ENGLISH PROFICIENCY POLICY AND PROCEDURE

 

 

1.

 

 

 

 

 

 

It is the general policy of Fentress County, Tennessee, not to discriminate against anyone with Limited English Proficiency (LEP), who participates in our programs and/or services. We have taken steps to ensure that all individuals will be able to communicate, either through written or oral language services, with all members of our staff. Fentress County adopts the following language assistance procedures for situations in which LEP individuals need direct services or information and to ensure compliance with the Executive Order 13166.

2.

Employees will have access to “I Speak” cards.  See attachment.

3.

 

Once language proficiency is determined, employees will have resources available to assist the individual in determining his/her need.

4.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If the need is urgent or life threatening, employees will defer to their supervisors what steps need to be taken. The steps are, but not limited to, the following:

 

·         If the need is a document translated, the supervisor will have the document translated as soon as possible, without jeopardizing his/her duties as a supervisor.

 

·         If the need is oral language services, the supervisor will take appropriate actions to provide the assistance as soon as possible through a translation service, without jeopardizing his/her duties as a supervisor.

 

·         The supervisor has the obligation to the safety of his/her employees as well as the people of Fentress County to assist the need of all persons. This includes not leaving his/her work place unless it is an emergency.

 

·         If the need is urgent or life threatening, employees will use, to the best of their ability, any resource available to accommodate the individual.

 

·         Any person who thinks there has been discrimination against him/her because of LEP should contact Vickie Reagan, Title VI Coordinator. Ms. Reagan will confer with the necessary individual(s) within the Title VI Division of the State of Tennessee and the County Attorney of Fentress County.

 

 

 

 

 

 

 

 

 

 

 

NEW EMPLOYEE ORIENTATION TO TITLE VI

 

 

STATEMENT OF POLICY:

 

 

 

 

No person shall, on the grounds of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.

 

All employees of Fentress county government are expected to consider, respect and observe this policy in their daily work and duties.  If a citizen approaches you with a discrimination question or complaint that appears to be based on some type of discrimination, direct the citizen to the Title VI Coordinator, Amanda Hicks, Executive Assistant, and is located in the Fentress County Courthouse, Office of County Executive, 101 Main Street; Jamestown, TN  38556.  Phone Number is 931-879-7713

 

 

 

 

 

 

 

 

          Employee Signature                                                               Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TITLE VI ACKNOWLEDGEMENT

 

 

 

BY SIGNING THIS FORM, I ACKNOWLEDGE I HAVE RECEIVED A

COPY OF THE FENTRESS COUNTY GOVERNMENT TITLE VI POLICY, TITLE VI COMPLAINT PROCEDURES, AND LIMITED ENGLISH PROFICIENCY POLICY AND PROCEDURES.

 

 

 

 

 

         SIGNATURE                                                                PRINT NAME

 

 

 

_______________________

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TITLE VI

 

COMPLAINT PROCEDURES

 

1.

 

 

 

A complaint alleging discrimination against Fentress County may be filed with the Fentress County Executive office, specifically the Title VI Coordinator or his/her designee. The Title VI Coordinator will determine jurisdiction and investigate or forward complaint to proper agency.

2.

 

 

Complaints filed against departments of Fentress County Government will be logged and forwarded to the Civil Rights Office, Title VI Program, 205 Deaderick Street, Suite 1800, Nashville, TN 37243

3.

 

 

 

 

 

 

 

 

The Title VI Coordinator is designated to receive, acknowledge and investigate complaints and preparing final reports and recommending compliances/corrective action. Complaints must be filed in writing, including the name, address, phone number, detailed description of the alleged discriminatory act and signature of complainant and immediately sent to the Title VI Coordinator. The complaint must be filled within 180 calendar days of the alleged incident. The form can be filled out by the complainant or by his/her representative. Title VI Coordinator should retain the original complaint but a copy shall be provided to the department or person that the complaint is filed against.

4.

 

 

Complaints filed against contractors, sub-contractors, etc. of Fentress County Government will be processed and investigated by the Title VI Coordinator or his/her designee. Contractor(s) should receive a copy of any complaint filed.

5.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

·         Unless a complaint is being filed externally, all complaints should first be filed with the Coordinator. The Coordinator will immediately log the complaint and forward an initial report to TDOT within seven working days.

 

·         The Coordinator will forward a copy of the complaint to the individual and/or contractor official including the phone number of the Title VI officer assigned to investigate the complaint.

 

·         The investigation officer will initiate the investigation by contacting the complainant within three workdays of receiving the assignment to set up an interview and inform the complainant they have a right to have a witness or representative present during the interview and submit any documentation he/she perceives as relevant to proving his/her complaint. The Coordinator’s investigative efforts regarding any complaints will be conducted in cooperation with the individual and/or contractor and the County Attorney has broad latitude to review a complaint and making a finding. Procedures can include, but are not limited to, discussing the complaint with the complainant, the alleged offender, and the initial reviewer, to determine the facts.

 

·         The investigating officer will conduct and complete such fact-finding within sixty (60) consecutive calendar days after receipt of the complaint. Once the investigation is completed, the Coordinator will prepare a written report of findings including the written complaint containing the allegation, basis, and date of filing; summarized statements taken from witnesses, finding of facts; opinion (based on all evidence in the record) that the incident is substantiated or unsubstantiated. If the report includes a finding of violation of the Title VI, the Title VI Coordinator should include the individual and/or Contractor and /or sub contractor’s proposed corrective action in the report. The Title VI Coordinator will determine appropriate corrective action. All corrective actions must be implemented within sixty days from the date of the actual recommendation. If the recommended corrective action has not been taken within the time period allowed, the individual and/or contractor and/or sub-contractor will be found to be in noncompliance with Title VI and the implementing rules and regulations and a referral will be made to TDOT for enforcement action.

 

·         The Coordinator will maintain a Title VI complaint log to show identifying information, type, and status of each complaint filed. When any investigation is concluded, the Coordinator will keep a copy of the report on permanent file. Within five (5) consecutive work days after the completion of this report, the written findings will be communicated to this complainant.

6.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPEALS PROCEDURES:

 

·         The Complainant has the right to appeal all written reports to the Federal Highway Administration.

 

·         The appeal must be made in writing to the TDOT Title VI Director within fourteen (14) days of receipt of Fentress County Government’s final report.

 

 

·         The appeal must specifically cite the portion(s) of the finding with which the complainant disagrees and his/her reason(s) for disagreement.

 

·         The TDOT Title VI Director will forward this appeal within seven (7) days to the Federal Highway Administration for review.

 

·         The FHWA review of the findings will be based on the entire record.

 

·         The FHWA must complete the appeal review thirty (30) calendar days after receipt of the appeal.

 

·         The FHWA will forward their written findings to the complainant and the TDOT Commissioner/Civil Rights Office.

 

 

EXTERNAL COMPLAINT INFORMATION

 

 

 

State of Tennessee

Department of Economic & Community Development

William R. Snodgrass Tennessee Tower

312 Eight Avenue North, Eleventh Floor

Nashville, TN 37243-0405

 

Summer Carr Title VI Coordinator

Phone: (615) 253-1944

Fax:     (615) 532-1296

 

 

 

Complaints may also be filed with:

 

Tennessee Title VI Compliance Commission

Tennessee Department of Personnel

First Floor, James K. Polk Building

505 Deaderick Street

Nashville, TN 37243-0635

 

Tiffany Taylor, Director

Tennessee Title VI Compliance Commission

Phone: (615) 532-4882

Fax:     (615) 532-0728

 

 

Complaints filed by persons other than applicants, recipients or beneficiaries must give the name and location of the person for whom the complaint is being made.

 

Each complaint will be investigated promptly. If you file a complaint, you will be notified of the findings, and corrective action will be taken immediately as needed.

 

 

TITLE VI

 

DISCRIMINATION COMPLAINT

 

 

COMPLAINANT CONTACT INFORMATION.

Provide your name and address.

 

____________________________________     ____________________________________

NAME                                                                                    ADDRESS

 

____________________________________     ____________________________________

CITY                                                       STATE                    ZIP                                                          COUNTY

 

____________________________________     ____________________________________

TELEPHONE                                                                         CELL

 

____________________________________     ____________________________________

E-MAIL                                                                                  DATE OF BIRTH

 

 

 

RESPONDENT CONTACT INFORMATION.

Provide the name and address of party(ies) that you believe discriminated against you:

 

____________________________________     ____________________________________

NAME                                                                                    ADDRESS

 

____________________________________     ____________________________________

TYPE OF BUSINESS                                                            CITY                                       STATE                    ZIP

 

____________________________________     ____________________________________

TELEPHONE                                                                         COUNTY

 

 

 

 

WHEN DID THE DISCRIMINATORY ACT(S) OCCUR?

 

Beginning date of the alleged discriminatory act?          _______________________________

 

Most recent date of the alleged discriminatory act?        _______________________________

 

Is the alleged discriminatory act ongoing?  oYES   oNO

 

 

 

 

 

BASIS OF DISCRIMINATION:

 

RACE: _______________________________ COLOR: __________________________

 

NATIONAL ORIGIN: _________________________

BACKGROUND ON THE ALLEGED DISCRIMINATION

 

Which of following action(s) were taken against you? (Check only those that apply and describe below.)

 

oDENIED PROGRAM SERVICE, AID, OR BENEFIT

 

oRECEIVED SERVICE OR BENEFIT DIFFERENTLY OR INFERIOR TO THOSE  

   PROVIDED TO OTHERS

 

oSUBJECTED TO SEGREGATE OR SEPARATE TREATMENT RELATED TO THE  

   RECEIPT OF ANY SERVICE OR BENEFIT

 

oDENIED OPPORTUNITY TO PARTICIPATE AS MEMBER OF PLANNING OR

   ADVISORY BODY

 

oRETALIATED AGAINST AS A RESULT OF ALLEGING ANY OF THE ABOVE

 

oOTHER _______________________________________________________________

 

 

 

IN YOUR OWN WORDS TELL US WHAT HAPPENED. Give dates, when applicable. Also, describe how others were treated differently than you.  Use additional paper if needed.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

____________________________________          ____________________________________

Complainant Signature                                                                 Date

 

 

WITNESSES: Please list any individuals that may have information that supports or clarifies your complaint. Include as much contact information as possible. This list will not be provided to the /respondent(s) named in your complaint.

 

____________________________________     ____________________________________

NAME                                                                                    ADDRESS

 

____________________________________     ____________________________________

CITY                                                       STATE                    ZIP                                                          COUNTY

 

____________________________________     ____________________________________

TELEPHONE                                                                         CELL

 

 

____________________________________     ____________________________________

NAME                                                                                    ADDRESS

 

____________________________________     ____________________________________

CITY                                                       STATE                    ZIP                                                          COUNTY

 

____________________________________     ____________________________________

TELEPHONE                                                                         CELL

 

 

____________________________________     ____________________________________

NAME                                                                                    ADDRESS

 

____________________________________     ____________________________________

CITY                                                       STATE                    ZIP                                                          COUNTY

 

____________________________________     ____________________________________

TELEPHONE                                                                         CELL

 

 

____________________________________     ____________________________________

NAME                                                                                    ADDRESS

 

____________________________________     ____________________________________

CITY                                                       STATE                    ZIP                                                          COUNTY

 

____________________________________     ____________________________________

TELEPHONE                                                                         CELL

 

 

____________________________________     ____________________________________

NAME                                                                                    ADDRESS

 

____________________________________     ____________________________________

CITY                                                       STATE                    ZIP                                                          COUNTY

 

____________________________________     ____________________________________

TELEPHONE                                                                         CELL