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Discrimination Complaint Form

Please provide the following information in order for us to process your complaint. This form is available in alternate formats and multiple languages. Should you require these services or any other assistance in completing this form, please let us know.

Name:________________________________________________________________

Address:______________________________________________________________

Telephone Numbers: (Home)____________(Work)____________(Cell)____________

Email Address:_________________________________________________________

Please indicate the nature of the alleged discrimination:

Categories protected under Title VI of the Civil Rights Act of 1964:

☐ Race ☐ Color ☐ National Origin (including limited English Proficiency)

Additional categories protected under related Federal and/or State laws/orders:

☐ Disability	☐ Age	☐ Sex
☐ Sexual Orientation	☐ Religion	☐ Ancestry
☐ Gender	☐ Ethnicity	☐ Gender Identity
☐ Gender Expression	☐ Creed	☐ Veteran’s Status
☐ Background

Who do you allege was the victim of discrimination?

☐ You ☐ A Third Party Individual ☐ A Class of Persons

Name of individual and/or organization you allege is discriminating:

_____________________________________________________________________

Do you consent to the investigator sharing your name and other personal information with other parties to this matter when doing so will assist in investigating and resolving your complaint?

☐ Yes ☐ No

Please describe your complaint. You should include specific details such as names, dates, times, witnesses, and any other information that would assist us in our investigation of your allegations. Please include any other documentation that is relevant to this complaint. You may attach additional pages to explain your complaint.

________________________________________________________________________________________

Have you filed this complaint with any other agency (Federal, State, or Local)?

☐ Yes ☐ No

If yes, please identify:__________________________________________________

Have you filed a lawsuit regarding this complaint?

☐ Yes ☐ No

If yes, please provide a copy of the complaint.

Signature: ____________________________________ Date:___________________

Mail to:

Title VI Specialist, Boston Region Metropolitan Planning Organization, 10 Park Plaza, Suite 2150, Boston, MA 02116

Title VI Coordinator, MassDOT Office of Diversity and Civil Rights, Suite 3800, 10 Park Plaza, Boston, MA 02116

Email to:

civilrights@ctps.org

MassDOT.CivilRights@state.ma.us