Title VI Complaint Form Page

Any person who believes that they have, individually or as a member of any specific class of persons, been subjected to discrimination on the basis of race, color, national origin, sex, age, disability, creed/religion, Limited English Proficiency (LEP), or any other federally protected basis, may file a complaint with the NWSA within 180 days of the date of the alleged discrimination.

Indicates required field

ABOUT YOU

First

Last

Phone

Best time of day to contact you about this complaint

Address

City/Town

State/Province

ZIP/Postal Code

ABOUT THE ALLEGED INCIDENT

Basis of Complaint (check all that apply):

Race

Color

National Origin (includes language access)

Date of alleged incident

What is the name of the person who discriminated against you?

First

Last

What is their address?

Address

City/Town

State/Province

ZIP/Postal Code

Description

Explain what happened, why you believe it happened, and how you were discriminated against. Indicate who was involved. Be sure to include how other persons were treated differently than you. If you have any other information about what happened, please attach supporting documentation to the form.

Remedy

What remedy are you seeking for the alleged discrimination? Please note that this process will not result in the payment of punitive damages or financial compensation.

Witnesses

List any other persons that we should contact for additional information in support of your complaint. Please list their names, phone numbers, address, email address below.

Have you filed your complaint, grievance, or lawsuit with any other agency or court?

Who?

When?

Status (pending, resolved, etc.)

Result, if known:

Complaint number, if known:

Do you have an attorney in this matter?

Yes

Name

Phone

Address

City/Town

State/Province

ZIP/Postal Code

CERTIFICATION

Attestation

I hereby certify that, to the best of my knowledge, the provided
information is true and accurate

First

Last

Date

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.