Compliment Suggestion Complaint Other VI: [ ] Race [ ] Color [ ] National Origin ADA (Disability): [ ] Yes [ ] No Service: [ ] Yes [ ] No Other: [ ] Gender [ ] Religion [ ] Age [ ] Limited English Proficient LEP SECTION II: CONTACT INFORMATION Name: Rider ID (if applicable): Street Address: City, State, Zip code: Phone: Email: Accessible Format Requirements: Audio Large Print TDD/Relay Other (choose preferred format(s) Recording Yes No Are you filing this complaint on your own behalf? If you answered to this question, go to Section IV. “yes” If not, please provide the name and relationship of the person for whom you are complaining: Please explain why you have filed for a third party: Yes No Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party. SECTION III: COMMENT DETAILS Transit Service (Choose one, as applicable) Bus/Paratransit/Shared-Ride Taxi Date of Occurrence: Time of Occurrence: Name/ID of Employee(s) or Others Involved: Vehicle ID/Route Name or Number: Direction of Travel: Location of Incident: Mobility Aid Used (if any): If above information is unknown, please provide other descriptive information to help identify the employee: Description of Incident: As applicable, explain as clearly as possible what happened and why you believe you were discriminated against. If more space is needed, please add additional pages. SECTION IV: FOLLOW-UP
Compliment Suggestion Complaint Other VI: ADA (Disability): Service: Other: [ ] Race [ ] Color [ ] National Origin [ ] Yes [ ] No [ ] Yes [ ] No [ ] Gender [ ] Religion [ ] Age [ ] Limited English Proficient LEP SECTION II: CONTACT INFORMATION Name: Rider ID (if applicable): Street Address: City, State, Zip code: Phone: Email: Accessible Format Requirements: (choose preferred format(s) Large Print TDD/Relay Audio Recording Other Are you filing this complaint on your own behalf? If you answered “yes” to this question, go to Section IV. Yes No If not, please provide the name and relationship of the person for whom you are complaining: Please explain why you have filed for a third party: Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party. Yes No SECTION III: COMMENT DETAILS Transit Service (Choose one, as applicable) Bus/Paratransit/Shared-Ride Taxi Date of Occurrence: Time of Occurrence: Name/ID of Employee(s) or Others Involved: Vehicle ID/Route Name or Number: Direction of Travel: Location of Incident: Mobility Aid Used (if any): If above information is unknown, please provide other descriptive information to help identify the employee: Description of Incident: As applicable, explain as clearly as possible what happened and why you believe you were discriminated against. If more space is needed, please add additional pages. SECTION IV: FOLLOW-UP
title6-temp.docx