Mark Twain Behavioral Health TITLE VI COMPLAINT FORM

Mark Twain Behavioral Health TITLE VI COMPLAINT FORM
“No person in the United States shall, on the basis of race, color, or national origin, be excluded from
participation in, be denied the benefits of, or be subjected to discrimination under any program or
activity receiving Federal financial assistance.”
If you feel that you have been discriminated against in the provision of transportation services, please
provide the following information to assist us in processing your complaint. Should you require any
assistance in completing this form or need information in alternate formats, please let us know.
Please mail or return this form to:
Celia Hagan, Title VI Coordinator
Mark Twain Behavioral Health
917 Broadway
Hannibal, MO 63401
Email: [email protected]
Fax: 573.221.4380
PLEASE PRINT
1. Complainant’s Name:
a. Address:
b. City:
State:
Zip Code:
c. Telephone (include area code): Home ( )
or Cell ( )
Work ( )
or other ( )
d. Electronic mail (e-mail) address:
Do you prefer to be contacted by this e-mail address? ( ) YES ( ) NO
2. Accessible Format of Form Needed? ( ) YES specify:_________________________ ( ) NO
3. Are you filing this complaint on your own behalf? ( ) YES If YES, please go to question 7.
( ) NO If no, please go to question 4
4. If you answered NO to question 3 above, please provide your name and address.
a. Name of Person Filing Complaint:
b. Address:
c. City:
State:
Zipcode:
d. Telephone (include area code): Home ( ) or Cell ( )
Work
( )
( )
e. Electronic mail (e-mail) address:
Do you prefer to be contacted by this e-mail address? ( ) YES ( ) NO
5. What is your relationship to the person for whom you are filing the complaint?
6. Please confirm that you have obtained the permission of the aggrieved party if you are filing on
behalf of a third party. ( ) YES, I have permission. ( ) NO, I do not have permission.
7. I believe that the discrimination I experienced was based on (check all that apply):
( ) Race ( ) Color ( ) National Origin (classes protected by Title VI)
( ) Other (please specify)
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8. Date of Alleged Discrimination (Month, Day, Year):
9. Where did the Alleged Discrimination take place?
10. Explain as clearly as possible what happened and why you believe that you were discriminated
against. Describe all of the persons that were involved. Include the name and contact information
of the person(s) who discriminated against you (if known). Use the back of this form or separate
pages if additional space is required.
11. Please list any and all witnesses’ names and phone numbers/contact information. Use the back of
this form or separate pages if additional space is required.
12. What type of corrective action would you like to see taken?
13. Have you filed a complaint with any other Federal, State, or local agency, or with any Federal or
State court? ( ) YES If yes, check all that apply. ( ) NO
a. ( ) Federal Agency (List agency’s name)
b. ( ) Federal Court (Please provide location)
c. ( ) State Court
d. ( ) State Agency (Specify Agency)
e. ( ) County Court (Specify Court and County)
f. ( ) Local Agency (Specify Agency)
14. If YES to question 13 above, please provide information about a contact person at the agency/court
where the complaint was filed.
Name:
Title:
Agency:
Telephone: ( )
Address:
City:
State:
Zip Code:
You may attach any written materials or other information that you think is relevant to your complaint.
Signature and date is required:
________________________________
Signature
______________________________
Date
If you completed Questions 4, 5 and 6, your signature and date is required:
________________________________
Signature
September 2014
______________________________
Date
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