Orange County NC Website
Browse       Search
DocuSign Envelope ID:3FDDF183-DEOC-45F5-AE17-OB9CF99E613F <br /> Orange County Public Transportation <br /> DISCRIMINATION COMPLAINT FORM <br /> Any person who believes that he/she has been subjected to discrimination based upon race,color,creed,sex,age,national origin,or disability <br /> may file a written complaint with Orange County Public Transportation,within 180 days after the discrimination occurred. <br /> Last Name: First Name: ❑ Male <br /> ❑ Female <br /> Mailing Address: City State Zip <br /> Home Telephone: Work Telephone: E-mail Address <br /> Identify the Category of Discrimination: <br /> ❑ RACE ❑ COLOR ❑ NATIONAL ORIGIN ❑SEX <br /> ❑ CREED(RELIGION) ❑ DISABILITY ❑ LIMITED ENGLISH PROFICIENCY ❑AGE <br /> 'NOTE:Title VI bases are race,color,national origin.All other bases are found in the"Nondiscrimination Assurance"of the FTA Certifications&Assurances. <br /> Identify the Race of the Complainant <br /> ❑ Black ❑White ❑ Hispanic ❑Asian American <br /> ❑American Indian ❑Alaskan Native ❑ Pacific Islander ❑ Other <br /> Date and place of alleged discriminatory action(s).Please include earliest date of discrimination and most recent date of discrimination. <br /> Names of individuals responsible for the discriminatory action(s): <br /> How were you discriminated against?Describe the nature of the action,decision,or conditions of the alleged discrimination. Explain as clearly <br /> as possible what happened and why you believe your protected status(basis)was a factor in the discrimination. Include how other persons <br /> were treated differently from you.(Attach additional page(s),if necessary). <br /> The law prohibits intimidation or retaliation against anyone because he/she has either taken action,or participated in action,to secure rights <br /> protected by these laws. If you feel that you have been retaliated against,separate from the discrimination alleged above, please explain the <br /> circumstances below. Explain what action you took which you believe was the cause for the alleged retaliation. <br /> Names of persons(witnesses,fellow employees,supervisors,or others)whom we may contact for additional information to support or clarify <br /> your complaint: (Attached additional page(s),if necessary). <br /> Name Address Telephone <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 17 <br />