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24 <br /> D. OCTS- Discrimination Complaint Form <br /> Any person v1ho believes that he/she has been subjected to discrimination based upon race,color,creed,sex,age,national ofigin,or disability <br /> may file a written complaint with Ofange County Tfansportation Services,within 180 days after the discrininAon occurred. <br /> Last Name. First Name, ❑ Male <br /> Female <br /> Mailing Address. City State Zip <br /> Home Telephone: Mork Telephone FE-mail Address <br /> Identify the Category of Discrimination. <br /> 13 RACE [3 COLOR ❑NATIONAL ORIGIN ❑SEX <br /> ❑CREED(RELIGION) ❑DISABILITY ❑LIMITED ENGLISH PROFICIENCY ❑AGE <br /> 'NOTE-Title N bases are race color national ongo AN oMerbases are hand k'Jre'Nondiscrnrunation Assurance'of the FTA Ceni i:wrons d Assurances <br /> Identity 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 acbon(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 inaction.to secure rights <br /> protected by these laws.If you feel that you have been retaliated against,separate from the discrimination alleged above,and please explain <br /> the 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 of clan4 <br /> your complaint: (Attached additional page(s). if necessary) <br /> Name Address Telephone <br /> 1. <br /> 2. <br /> 3. <br /> 4. <br /> 171Page <br />