DISCRIMINATION COMPLAINTS LOG Log Year(s): CASE COMPLAINANT RACE/ RESPONDENT BASIS DATE DATE ACTION TAKEN DATE DISPOSITION NO. NAME GENDER NAME FILED RECEIVED INVESTIG. COMPLETED No Complaints or Lawsuits I certify that to the best of my knowledge, the above described complaints or lawsuits alleging discrimination, or no complaints or lawsuits alleging discrimination, have been filed with or against Official Organization Name since the previous Title VI Program submission to NCDOT. _______________________________________________________________ ______________________________ Signature of Title VI Coordinator or Other Authorized Official Date _______________________________________________________________ Print Name and Title of Authorized Official
DISCRIMINATION COMPLAINTS LOG Log Year(s): CASE NO. COMPLAINANT NAME RACE/ GENDER RESPONDENT NAME BASIS DATE FILED DATE RECEIVED ACTION TAKEN DATE INVESTIG. COMPLETED DISPOSITION No Complaints or Lawsuits I certify that to the best of my knowledge, the above described complaints or lawsuits alleging discrimination, or no complaints or lawsuits alleging discrimination, have been filed with or against Official Organization Name since the previous Title VI Program submission to NCDOT. _______________________________________________________________ ______________________________ Signature of Title VI Coordinator or Other Authorized Official Date _______________________________________________________________ Print Name and Title of Authorized Official
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