Title VI and Other Discrimination Complaint Form

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Personal Information

Date*

Name*

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Phone number

Preferred email*

Preferred method of contact*

Best time to contact you:

Are you represented by an attorney? *

Yes No

Attorney name:

Attorney phone number:

Attorney email address:

Information of agency, business or contractor that allegedly discriminated

Date discrimination occurred:

Most recent date of discrimination (if different from above)

Agency, business or contractor name:

Phone number

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Name(s) and job title(s) of individual(s) who allegedly discriminated:

Tell Us What Happened

Please explain in detail what happened, who was involved, and how you or other persons were discriminated against. If necessary, provide a copy of written materials pertaining to your complaint: *

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What is Your Desired Outcome?

Briefly explain how you would like this matter to be resolved:

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Verification

I understand that checking this box constitutes a legal signature confirming that I, the submitter for this form, warrant the truthfulness of the information provided.

Privacy notice: MnDOT is asking you to provide information in this complaint form which includes private and/or confidential information under the Minnesota Government Data Practices Act. MnDOT is asking for this private/confidential information so that it can investigate and respond to allegations of discrimination. You are not legally required to provide this information. However, if you do not provide sufficient information, MnDOT may not be able to properly investigate your complaint. The information you provide will be used by MnDOT employees whose job assignments reasonably require access to the information. The following also have a legal right to access the information: exclusive representative for any MnDOT employee who becomes the subject of investigation in connection with your complaint; the arbitrator if discipline imposed on any such employee is appealed to arbitration; the MN Attorney General’s Office; the MN Legislative Auditor’s Office; law enforcement agencies and prosecutorial authorities; persons/entities named pursuant to court order; persons/entities whom you authorize; and any other person or entity authorized by state or federal law.

Personal Information

Basis of the Discrimination

Information of agency, business or contractor that allegedly discriminated

Tell Us What Happened

What is Your Desired Outcome?

Verification