Pierce County Human Services Transportation Title VI / ADA Complaint Form

Please complete this form to the best of your ability. If you need translation or other assistance, contact Daeveene May.

1. Contact Information *This question is required.

Name

Address

City

Zip

Email: This question requires a valid email address.

Phone: Home

Work

Mobile

2. Best time of day to contact you about this complaint:

3. Date of alleged incident: This question requires a valid date format of MM/DD/YYYY.

calendar

4. Basis of complaint (check all that apply):

Race
Color
National Origin
Disability Status

5. Who discriminated against you?

Name

Name of Organization

Address

City

Zip

Telephone

6. Explain what happened, why you believe it happened, and how you were discriminated against. Indicate who was involved. Be sure to include how other persons were treated differently than you. If you have any other information about what happened, please attach supporting documentation to the form. (Attach additional pages if more space is needed.)

7. What remedy are you seeking for the alleged discrimination? Please note that this process will not result in the payment of punitive damages or financial compensation.

8. Upload any supporting documentation or attachments here.

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