VILLAGE OF NASHVILLE
TITLE VI
DISCRIMINATION COMPLAINT FORM
In order for us
to properly assist you in processing your complaint, the following information is needed:
1.
Complainant’s Name:
Address:
_______________________________________
City, State, Zip Code:
_______________________________________
Telephone Number (home): _______________________________________
(business): _______________________________________
2.Person discriminated
against (if someone other than complainant):
Name:
_______________________________________
Address:
_______________________________________
City, State, Zip Code:
_______________________________________
Telephone Number (home):
_______________________________________
3. What is the name and location of
Village Department or agency that you believe discriminated against you?
Name:
_______________________________________
Address:
_______________________________________
City, State, Zip Code:
_______________________________________
Telephone Number:
_______________________________________
4. Which of the following best describes the reason you believe the
discrimination took place?
Was it because of your:
a. Race/Color (specify)
_______________________________________
b. National Origin (specify)
__________________________________________
5. What date did the alleged discrimination take place?
___________________________________________________________________
____________________________________________________________________
6.
In your own words, describe the alleged discrimination. Explain what happened and whom you believe was responsible.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Do you have any witnesses to verify your allegations?
YES______ NO _______
If YES,
Name:
_____________________________________________
Address:
_____________________________________________
City, State, Zip Code:
_____________________________________________
Telephone Number:
_____________________________________________
7. Have you tried to resolve this complaint through the internal
grievance procedure at the accused department or agency?
YES______ NO _______
If YES, what is the
status of the grievance?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
Name and title of
the person handling the grievance procedure.
Name:
______________________________________________
Title:
______________________________________________
Telephone Number:
______________________________________________
8. Have you filed this complaint
with any other federal, state or local agency; or with any federal or state court?
YES______
NO _______
If YES, check
all that apply:
Federal Agency
___ State Court
___ State Agency
___
Federal Court ___
Local Agency ___
Please provide information about a contact person at the
agency/court (where the complaint was filed)
Name:
__________________________________________
Address:
__________________________________________
City, State, Zip Code:
__________________________________________
Telephone Number:
__________________________________________
9. Do you intend to file this complaint with another agency?
YES______
NO _______
If YES,
when and where do you plan to file the complaint?
Date:
__________________________________________
Agency:
__________________________________________
Address:
__________________________________________
City, State, Zip Code:
__________________________________________
Telephone Number:
__________________________________________
10. Has this complaint been filed with
this agency before?
YES______ NO _______
If YES, when? Date ________
11. Have you filed any other complaints with this agency?
YES______
NO _______
If
YES, when and against whom were they filed?
Date:
__________________________________________
Name:
__________________________________________
Address:
__________________________________________
City, State, Zip Code:
__________________________________________
Telephone Number:
__________________________________________
Give a brief description of the other complaint.
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
What is the status
of the other complaint?
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
12.
Are you represented by an attorney with regard to anything related to this matter?
YES______
NO _______
If YES, please
fill in the following:
Attorney’s
Name:
__________________________________________
Address:
__________________________________________
City, State, Zip Code:
__________________________________________
Telephone Number:
__________________________________________
13. Please sign below. You may attach any
written materials or other information that you think is relevant to your complaint.
__________________________________
_______________
Complainant Signature
Date