Complaint Form: If You Feel Discriminated Against

Page 1

Missouri Division of Workforce Development

WIOA (Workforce Innovation and Opportunity Act) GENERAL COMPLAINT Complainant Information (please print or type) FIRST NAME

LAST NAME

HOME STREET ADDRESS

TELEPHONE NUMBER (include Area Code)

CITY

STATE

ZIP CODE

EMAIL ADDRESS (if available)

MO Complainants with disabilities will be accommodated during the complaint process. If an accommodation is required regarding communication or accessibility of location, please indicate in the space below the kind of accommodation required, e.g. accessible location, deaf interpreter (please indicate type of sign language), notification of results and/or hearing dates in alternative format such as Braille, large print, or audio format.

Respondent Information (the person or entity that the complaint is being filed against) (please print or type) NAME of PERSON OR AGENCY

TELEPHONE NUMBER (include Area Code)

STREET ADDRESS OF AGENCY

CITY

STATE

ZIP CODE

EMAIL ADDRESS (if available)

MO Nature of Complaint (please print or type) Provide a clear and brief statement of the facts in the space below. Include relevant dates that will assist in the investigation and resolution of the complaint. If additional space is needed, use the reverse side of this form or attach additional sheets.

Attest: "The above information is true and correct to the best of my knowledge."

Signature of Complainant

Date

FOR OFFICIAL USE ONLY PERSON RECEIVING COMPLAINT

JOB TITLE/AGENCY

STREET ADDRESS OF AGENCY

CITY

STATE

ZIP CODE

MO TELEPHONE NUMBER (include Area Code)

EMAIL ADDRESS

DWD-104 (03-2019) For additional information about Missouri Division of Workforce Development services, contact a Missouri Job Center near you. Locations and additional information are available at jobs.mo.gov or (888) 728-JOBS (5627). Missouri Division of Workforce Development is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities. Missouri Relay Services are available at 711.