Online Complaint Form ADA Complaint Form I wish to file a complaint about: Please Select An OptionTitle VI (Civil Rights Act) ComplaintGeneral ComplaintAmericans with Disabilities Act (ADA) Compliant Title VI (Civil Rights Act) Complaint Title VI of the Civil Rights Act of 1964 states “No person in the United States of America shall, on the ground 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.” Please provide the following information necessary in order to process your complaint. Assistance is available upon request by calling the Title VI Coordinator at (559) 621-7433 or dial 711 California Relay Service. Fields marked with an asterisk (*) are required. If you wish to send attachments, you may include them at the end of this form.Complainant’s Information First Name * Middle Name Last Name * Address * Address (Cont.) City * State * Zip Code * Phone * Email * Person Allegedly Discriminated Against (If other than the complainant) First Name Middle Name Last Name Address City State Zip Code Phone Email Discriminatory Incident Incident location? (please provide location, bus number, drivers name, etc.) * Date of alleged incident * Discrimination based On * RaceColorNational Origin Description of the alleged discrimination. What happened and who was responsible? * What FAX representative(s) were allegedly involved? * Witnesses (Please provide the contact information for any witness to the incident) First Name Middle Last Name Address City State Zip Code Phone Email plus1 Add Witness minus1 Remove Witness Has the complaint been filed with the Department of Transportation or any other federal, state, or local civil rights agency or court? * NoYes, Federal CourtYes, Federal AgencyYes, State AgencyYes, State CourtYes, Local AgencyYes, Other Agency Point of Contact for the Agency you also Filed the Complaint With (Name): Address Phone Number Attachments Drop a file here or click to upload Choose File Maximum file size: 20MB Signature * signature keyboard Clear Signature Signature is Required General Complaint First Name * Middle Last Name * Address * Address (Cont.) City * State * Zip Code * Phone * Email * Incident Information Incident location (route number, bus stop number or location, transit facility, direction of travel) * Bus number (3 or 4 digit number label on the bus; for route number enter in the box above) Bus driver name/description Date of incident* * FAX incident number (if applicable) Description of the complaint * Attachments Drop a file here or click to upload Choose File Maximum file size: 20MB Signature * signature keyboard Clear Signature Signature is Required Americans with Disabilities Act (ADA) Compliant Americans with Disabilities (ADA) Act Discrimination Complaint Form This form may be used by anyone who wishes to file a complaint alleging discrimination on the basis of disability in the provision of services, activities, programs, or benefits by the City of Fresno. The City of Fresno does not investigate complaints of discrimination by other government entities or businesses. Fields marked with an asterisk (*) are required. If you wish to send attachments, you may include them at the end of this form. Person filling out this form First Name * Middle Last Name * Address * Address (Cont.) City * State * Zip Code * Phone * Email * Person Discriminated Against (if other than the complainant) First Name Middle Last Name Address City State Zip Code Phone Email Discriminatory Incident Incident location (route number, bus stop number or location, transit facility, direction of travel) * Bus number (3 or 4 digit number label on the bus; for route number enter in the box above) Bus driver name/description Date of incident * Primary type of disability MobilityCognitive / Intellectual/ DevelopmentLearningMental / PsychiatricVisionHearingSeizureSpeechHIV / AIDSDiabetesOther / Not listed / Decline to state Issue * EmploymentPhysical AccessInterpreting / Assistive LearningService AnimalRetaliationDenial of Service / Refuse to AdmitWeb / TechnologyOther Description of the acts of discrimination * Has the complaint been filed with the Department of Justice or any other federal, state, or local civil rights agency or court? * YesNo Agency or Court Attachments Drop a file here or click to upload Choose File Maximum file size: 209.72MB Signature * signature keyboard Clear Signature Signature Required Submit If you are human, leave this field blank.
