LAP Grievance Form English - Lancaster County Courts, PA

2nd Judicial District
Language Access Plan
Complaint Form Instructions
Should a court client/customer feel that his/her rights to meaningful language
access have not been met by the Court, the following procedure may be
followed to register a complaint:
1. The person with the complaint (the complainant) should contact the 2nd
Judicial District Language Access Coordinator to report the complaint by
completing and submitting the attached Language Access Complaint
Form.
Contact information: [Name and contact information, including address,
telephone number, fax, and email address, for judicial district's language
access coordinator.]
2. If the complainant does not believe that their concerns have been
adequately addressed or resolved with the 2nd Judicial District
language access coordinator, the complainant should contact the
Coordinator for Court Access at the Administrative Office of the
Pennsylvania Courts, (AOPC).
Contact information: Mary Vilter, Esq., 1515 Market Street, Suite 1414,
Philadelphia, PA 19102, phone: 215.560.6300, fax: 215.560.5485,
[email protected]
3. The complainant may also, at any time in this process, contact the United
States Department of Justice.
Contact information: Federal Coordination and Compliance Section, Civil
Rights Division, United States Department of Justice, 950 Pennsylvania
Avenue NW, Washington, D.C. 20530, (888) 848-5306 or (202) 307-2678
(TDD).
2ndJudicial District
Language Access Complaint Form
The 2nd Judicial District is committed to providing services to all members of the
community it serves, regardless of their ability to speak English, in compliance
with Title VI of the Civil Rights Act of 1964, PA Act 172 of 2006, and the
Regulations Governing Court Interpreters implemented by the Pennsylvania
Supreme Court. If you feel you have been denied services because of the
language you speak, please complete this form and bring it or send it to the
court as indicated.
The following information is necessary to assist us in processing your complaint.
Should you require assistance in completing this form, please contact the 2nd
Judicial District at [contact information of language access coordinator for judicial
district]:
Name: ___________________________________________________
Language Access Coordinator
2nd Judicial District
Street Address: _____________________________________________
City/State/Zip: _____________________________________________
Phone: ________________________ Fax: _____________________
Email: _____________________________________________________
1. Name of person filing complaint (the complainant):
2. What language do you prefer to communicate in:
3. Complainant’s Address:
4. Complainant’s Contact Information:
Home Phone:
Work Phone:
Mobile Phone:
E-mail:
5. If you are filing on behalf of another person, please include your name,
address, phone number, and relation to the complainant:
Name:
Address:
Phone:
E-mail:
Relationship to Complainant:
6. Please provide the following information about where and when your
rights to language access were not met.
Please write the date and time when you were at the courthouse.
Date________________________________ Time______________
Did you request language assistance?  Yes
 No
What was your business in the courthouse on that day?
______________________________________________________________________
______________________________________________________________________.
Were you in a courtroom when you felt that your language access rights
were not met?  Yes  No
If you were in a courtroom, please provide as much of the following
information as possible:
Name of your case _________________________________________
Case number ______________________________________________
Courtroom number _________________________________________
Judge’s name ______________________________________________
If you had an interpreter, write the interpreter's name here:
__________________________________________________________________
What was the interpreter’s language _______________________________
If you were not in a courtroom when you felt that your language access
rights were not met, where in the courthouse were you?
(For example, was it a clerk's counter, information counter? Somewhere
else in the courthouse?) Please write where in the courthouse the event
took place.
____________________________________________________________________
Do you know the name of the employee who handled your case? If so
write it here ________________________________________________________
Did the employee handling your case offer to provide some form of
language assistance?  Yes  No
If yes, what language assistance was offered? (For example, obtaining an
interpreter, printed information or documents in your language, etc.):
_____________________________________________________________________
_____________________________________________________________________
7. Please describe, in your own words, in what way you believe that your
rights to language access were not met and whom you believe was
responsible. Please use the back of this form or additional pages as
needed.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
8. Please sign below:
Signature______________________________________________________
Date Signed___________________________________________________
Return this form to:
__________________________________
Language Access Coordinator
2nd Judicial District
Address: __________________________________________________________
____________________________________________________________________