11.21.22 OUTBoard Packet - Laserfiche WebLink

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D. OCTS- Discrimination Complaint Form Any person who believes that he;slle has been subjected to discrimination based upon race,color,creed,sex,age,national origin,or disability mayfile awritten complaintwith Orange County Transportation Services,within 180 days after the discrimination occurred" Last Name: First Name: ❑ Dale Female Mailing Address: Gity State Zip Home Telephone: Work Telephone: E-mail Address Identify the Galegory of Discrimination_ ❑ RACE ❑OOLOR ❑ NATIONAL ORIGIN SEX ❑GREED(RELIGION) ❑ DISABILITY ❑ LIMITED ENGLISH PROFIGIENCY AGE WOTE.Title W bases are race.mkr n9keaforkyin.AL ocher bases aye found in the'Nond6crkrainedan Asal wipe'of the FTA C�-rfificalions&Assurances. Identify the Race of the Camplainard ❑ Black ❑While ❑ Hispanic ❑ Asian American ❑American Indian ❑Alaskan Native ❑ Pacific Islander ❑ Other Dale and place of alleged discriminatory action(s). Please include earliest date of discrimination and mast recent date of discrimination. Names of individuals responsibleforlhe discriminatory action(s)= Hc-,. ,'!ere you discriminated agains-? Dcscice -na ra-.ire c=-na action, decision, ar conditions of the alleged discrimination. Explain as clearly as Gass;hle v.haf haLi3ered and',,Ih,: ,:ou 1_-e ieve yD.ir Yrvtecterl 5-atus (basis]was a factor in the discrimination"Include how other persons ',:ere -'eaiac r1—?•-3nt1_, frorn'x'DJ. (,attach additional page(s), if necessary), The law prohibits intimidation or retaliation against anyone because helshe has eithertaken action, or participated in action,to secure rights protected by these lays. If you feel thal you have been relaiiated against, separale from the discrimination alleged above, and please explain the circumstances be low. Explain what action you took which you believe was the cause for the alleged retaliation. Names of persons(wilnesses,fellow employees,supervisors, or others)whom we may cordacl far additional information to support or clarify your complaint: (Attached additional page(s),if necessary)" Narne Address Telephone 1. 2. 3. 4.