General, ADA & Title VI Non-discrimination Complaint Form GENERAL, ADA & TITLE VI NON-DISCRIMINATION COMPLAINT FORM What type of complaint are you making? * General ComplaintADA ComplaintTitle VI Non-discrimination Complaint Check what you believe to be the basis for the discrimination against you. Check all that apply. * Race Color Religion Sex National Origin Hispanic or Latino American Indian or Alaska Native Black or African American Native Hawaiian or Other Pacific Islander Asian White OtherOther Have you filed a complaint with any other agency? * Yes No If yes, please list the name of the agency or agencies Date of incident If yes, please list the name(s) of department employees or programs/offices involved in discrimination and/or harassment (if known): Please list the name(s) of department employees or programs/offices involved in discrimination and/or harassment (if known): * Name(s) of any witnesses: * Explain Specific Complaint: * (Explain what happened, the date(s) incidents occurred, who was involved etc.) First Name * Last Name * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone * Email * All complaints need to be filed within 180 days of the last occurrence of discrimination and/or harassment. Signature * signature keyboard Clear If you are human, leave this field blank. Submit Δ