Title VI Complaint Form

Title VI Complaint Form Regarding a City of Fort Collins Service, Program or Activity

Title VI of the Civil Rights Act of 1964 requires that “no person in the United States 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.”

If you feel you have been discriminated against on the basis of race, color or national origin through the City of Fort Collins’ provision of any program or activity (pursuant to Title VI of the Civil Rights Act of 1964), please complete this Title VI Complaint Form.

Please complete all questions to the best of your knowledge. If you need assistance in completing this form, including interpretation or translation assistance, please contact the City’s Title VI Coordinator via email, at titlesix@fcgov.com, or by calling 970.416.4254.

PLEASE COMPLETE THE INFORMATION BELOW:

1. Complainant

Complainant's Name:

Address:

City:

State:

Zip code:

Telephone contact #:

Email:

2. Person discriminated against (if someone other than Complainant)

Name:

Address:

City:

State:

Zip code:

Telephone contact #:

Email:

Check all that apply.

3. Which of the following best describes the reason you believe the discrimination took place?

Race
Color
National Origin
Limited English proficiency

4. City of Fort Collins agency, department, or program complaint is about:

Name of Agency, Department, or Program:

City Employee(s) Involved:

5. Date of incident (resulting in complaint): This question requires a valid date format of MM/DD/YYYY.

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6. Location of incident (resulting in complaint):

7. In your own words, describe the circumstances surrounding this complaint. Please provide as many details as possible, such as time of day, specific actions, events, interactions, names and job titles, who said what, who was present at the time, etc.

Circumstances leading to this complaint:

8. Were there any witnesses to the incident?

Please provide as much information as possible about any witnesses.

Witness A:

Witness Name:

Address:

City:

State:

Zip code:

Telephone contact #:

Email:

Any other identifying details:

Please provide as much information as possible about any witnesses.

Witness B:

Witness Name:

Address:

City:

State:

Zip code:

Telephone contact #:

Email:

Any other identifying details:

9. Have any efforts been made to file or resolve this complaint through the internal grievance procedures of any City of Fort Collins department?

Which department?

What is the status of the grievance?

10. Have you filed a complaint about this same incident with any other agency or court?

If so, fill in the organization’s name and contact person:

Space Cell	Organization Name	Contact Person
Federal Agency:	Federal Agency:: Organization Name	Federal Agency:: Contact Person
Federal Court:	Federal Court:: Organization Name	Federal Court:: Contact Person
State Agency:	State Agency:: Organization Name	State Agency:: Contact Person
State Court:	State Court:: Organization Name	State Court:: Contact Person
City or Local Agency:	City or Local Agency:: Organization Name	City or Local Agency:: Contact Person
City or Municipal Court:	City or Municipal Court:: Organization Name	City or Municipal Court:: Contact Person

Other - Please provide the full contact information for the person with the “other” agency or court:

Name:
Affiliation:
Address:
City:
State:
Zip code:
Telephone number:
Date filed:

11. Type your name in the space below to provide an electronic signature.

12. Today's date: This question requires a valid date format of MM/DD/YYYY.

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13. In order to receive a copy of this complaint, please enter your email below: This question requires a valid email address.