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Public Works Title VI Complaint

Steps

  1. 1. Title VI Complaint
  2. 2. Continuation Sheet
  • Title VI Complaint

    1. County_Seal.jpg

    2. County of Humboldt

      Department of Public Works. . .... 1106 Second Street .. ... ... . .. Eureka, CA 95501-0579 ... .......... Ph: (707) 445-7491

    3. Title VI Discrimination Complaint

      Note: The use of the complaint form is not mandatory. You may submit your complaint in any form that includes your signature. Please sign and date the complaint form below.

    4. Representative

      If you have a representative, please provide the following information:

    5. Please describe the circumstances of the alleged discrimination and include date(s).

    6. Please be sure to explain as clearly as possible the nature of the action, 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).

    7. Names of individuals responsible for the discriminatory action(s):

    8. Names of Witness

      Names of individuals (witnesses, fellow employees, supervisors, or others) whom we may contact for additional information to support or clarify your complaint: