Civil Rights Form | AZO Civil Rights Form

Title VI Complaint Form

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First Name

Last Name

Date

Phone

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Complaint Information

Please indicate the basis of your complaint

Race

Age

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Disability

Input the date and place of alleged discriminatory action(s). Please include the earliest date of discrimination and the most recent date of discrimination.

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 actions you took which you believe was the cause for the alleged retaliations.

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

Input the names of persons (witnesses, fellow employees, supervisors, or others) whom we may contact for additional information to support or clarify your complaint. (Include name, address, and phone number)

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