10.19.22 OUTBoard Packet - Laserfiche WebLink

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