Title VI Complaint Form

Page 1

Title VI Program Complaint Form Missouri Department of Transportation External Civil Rights Division MoDOT is committed to ensuring that no person is excluded from participation in or denied the benefits of its services on the basis of race, color, national origin, disability, age, income status, or LEP, as provided by Title VI of the Civil Rights Act of 1964, and related nondiscrimination authorities. Title VI complaints must be filed within 180 days from the date of the alleged discrimination. The following information is necessary to assist us in processing your complaint. If you require any assistance in completing this form, please contact the Title VI Coordinator by calling (573)526-2978. The completed form must be returned to: MoDOT External Civil Rights Division, Title VI Coordinator, P.O. Box 270, Jefferson City, Missouri 65102-0270 or to TitleVI@modot.mo.gov Name:

Street Address, City, State and Zip:

Phone Number & Email Address:

Alternate Phone Number:

Name of person(s) discriminated against (if someone other than complainant):

Street Address, City, State and Zip:

Phone Number & Email Address:

Alternate Phone Number:

ACCESSIBLE FORMATS: This document is available in accessible formats upon request. To obtain paper copies of this complaint form as well as information regarding these accessible formats, call MoDOT’s External Civil Rights Division at (573)526-2978. Individuals with hearing impairments may contact the Missouri Relay Service at (800)735-2966 for assistance with the call.

Page 2

Title VI Program Complaint Form Please check the reason(s) for which you believe you were discriminated: 

Race

Color

National Origin

Date of Incident: Please describe the alleged discrimination incident. Provide the name and title of all individuals involved if available. Explain what happened and who you believe was responsible. You may attach any written materials or other information that you believe is relevant to your complaint.

Page 3

Title VI Program Complaint Form

Please list any witness(es) to the alleged discrimination: Name:

Street Address, City, State and Zip:

Phone Number & Email Address:

Name:

Street Address, City, State and Zip:

Phone Number & Email Address:

What corrective action would you like to see taken?

Page 4

Title VI Program Complaint Form

Have you filed a complaint with any other federal, state or local agency/ agencies/ court(s)?  Yes

 No

If so, please list the agencies in which you filed a complaint and provide their contact information: Agency:

Contact Person:

Street Address, City, State and Zip:

Phone Number & Email Address:

Agency:

Contact Person:

Street Address, City, State and Zip:

Phone Number & Email Address:

I affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief.

Complainant’s Signature

Date

Print Name of Complainant

Date