External Title VI Discrimination Complaint Form
Name
First Name
Last Name
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Race
Please Select
American Indian
Alaska Native
Asian
Black
African American
Native Hawaiian
Other Pacific Islander
White
Two Or More Races
Other
Other Race
Color
Please Select
Black
White
Asian
Other
Other Color
Ethnicity/National Origin
Please Select
Hispanic or Latino
Not Hispanic or Latino
Sex
Please Select
Male
Female
Gender
Please Select
Man
Woman
Non-Binary
Prefer Not To Say
Other
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).
Name
Address
Telephone
Person 1
Person 2
Person 3
Person 4
Person 5
Optional Additional Person List
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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.
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:
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