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Do OCTS ® 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 Transportation Services, within 180 days after the discrimination occurred . <br /> Last Name : First Name : 0 Male <br /> Female <br /> Mailing Address : City State Zip <br /> Horne Telephone : Work Telephone : E -mail Address <br /> Identify the Category of Discrimination : <br /> 0 RACE E] COLOR 0 NATIONAL ORIGIN 0 SEX <br /> 0 CREED ( RELIGION) 0 DISABILITY LIMITED ENGLISH PROFICIENCY 0 AGE <br /> *NOTE: Tede V1 bases are race, mar, natural ofigki, AR other bases are found in the Wondis 6atinat an Assurance* of the FTA Cedifiations S Assurances. <br /> Identify the Race of the Complainant <br /> Black White 0 Hispanic 0 Asian American <br /> 0 American Indian Alaskan Native 0 Pacific Islander 0 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 /> Hove 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 lave prohibits intimidation or retaliation against anyone because he/she has either taken action , or participated in action , to secure rights <br /> protected by these laves . 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 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 � Page <br />