External Title VI Discrimination Complaint Form

Name

First NameLast Name

Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Race

Other Race

Color

Other Color

Ethnicity/National Origin

Sex

Gender

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 weretreated 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):

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).

Rows	Name	Address	Telephone
Person 1
Person 2
Person 3
Person 4
Person 5

Optional Additional Person List

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.

Rows	Have You Filed?	Date(MM-DD-YYYY)
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: