Connecticut Department of Transportation TITLE VI DISCRIMINATION COMPLAINT FORM Complainants Name: ______________________________________________________ Street Address: __________________________________________________________ City, State, Zip: __________________________________________________________ Telephone #: _____________________________________ Discrimination because of: __Race/__Color/__National Origin/_Sex/__Age/__Disability/__Creed/__Other Please provide the date(s) and location of the alleged discrimination, the name(s) of the individual(s) who allegedly discriminated against you including their titles (if known). Please provide the names, addresses, and telephone numbers of any witnesses. Explain as briefly and as clearly as possible what happened, how you feel that you were discriminated against and who was involved. Please include how other persons were treated differently from you. Signature: Date: You may use additional sheets of paper if necessary. Also, include any written materials pertaining to your complaint. How can I file a discrimination complaint? If you believe that a USDOT recipient has discriminated against you or others protected by Title VI, you may file a complaint. Complaints filed with ConnDOT should be directed to: Debra Goss, Title VI Coordinator at 860-594-2169 or Scott Hoffman, Associate Title VI Coordinator, at 860-594-2246. Fax: 860-594-3016.
Connecticut Department of Transportation TITLE VI DISCRIMINATION COMPLAINT FORM Complainants Name: ______________________________________________________ Street Address: __________________________________________________________ City, State, Zip: __________________________________________________________ Telephone #: _____________________________________ Discrimination because of: __Race/__Color/__National Origin/_Sex/__Age/__Disability/__Creed/__Other Please provide the date(s) and location of the alleged discrimination, the name(s) of the individual(s) who allegedly discriminated against you including their titles (if known). Please provide the names, addresses, and telephone numbers of any witnesses. Explain as briefly and as clearly as possible what happened, how you feel that you were discriminated against and who was involved. Please include how other persons were treated differently from you. Signature: Date: You may use additional sheets of paper if necessary. Also, include any written materials pertaining to your complaint. How can I file a discrimination complaint? If you believe that a USDOT recipient has discriminated against you or others protected by Title VI, you may file a complaint. Complaints filed with ConnDOT should be directed to: Debra Goss, Title VI Coordinator at 860-594-2169 or Scott Hoffman, Associate Title VI Coordinator, at 860-594-2246. Fax: 860-594-3016.
title_vi_discrimination_complaint_form_revised.docx