I-70 COMMUNITY HOSPITAL TITLE VI COMPLAINT FORM “No

I-70 COMMUNITY HOSPITAL 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 fell 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:
Julie Davenport
I-70 Community Hospital
105 Hospital Drive
Sweet Springs, MO 65351
Phone: 660-335-4700
Fax: 660-335-7487
E-mail: [email protected]
PLEASE PRINT
1.
2.
3.
4.
5.
6.
Complainant’s Name:
a. Address :
b. City:
State:
Zip Code:
c. Telephone (include area code): Home ( ) or Cell ( )
Work:
( )
( )
d. Electronic mail (e-mail) address:
Do you prefer to be contacted by this e-mail address? ( ) YES ( ) NO
Accessible Format of Form Needed? ( ) YES specify:________________________________
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
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:
Zip Code:
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
What is your relationship to the person for whom you a filing the complaint?
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)
TITLE VI COMPLAINT FORM – PAGE 2
8.
9.
Date of alleged Discrimination ( Month, Day, Year):
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 14 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 material or other information that you think is relevant to your complaint.
Signature and date is required:
_______________________________________
Signature
________________________________
Date
If you completed Questions r, 5 and 6, your signature and date is required:
_______________________________________
Signature
________________________________
Date