ADA/Title VI Complaint Form

Background

This form is used for both Title VI and Americans with Disabilities Act (ADA) complaints.

The Civil Rights of 1964 (Title VI) identifies the three classes protected by Title VI—race, color, and national origin—and allow the complainant to select one or more of those protected classes as the basis/bases for discrimination. If any of the Limited English Proficient (LEP) populations in our service area meet the Safe Harbor threshold, then the procedure will be provided in English and in any other language(s) spoken by LEP populations that meet the Safe Harbor Threshold.

The Americans with Disabilities Act of 1990 (ADA), provides protection that no individual with a disability shall on the basis of disability, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any federally funded program, service, or activity.

Perry County Transit is committed to providing non-discriminatory service to ensure that no person is excluded from participation in, or denied the benefits of, or subjected to discrimination in the receipt of its services on the basis of race, color, or national origin as protected by Title VI of the Civil Rights Act of 1964 (Title VI) as well as providing protection that no individual with a disability shall on the basis of disability, be excluded from participation in, be denied the benefits of, or be subjected to discrimination as stated in the Americans with Disabilities Act of 1990 (ADA).

If you feel that you have been discriminated against, please provide the following necessary information to facilitate the processing of your complaint. If assistance is required to complete the form, or if you have questions, please do not hesitate to call the ADA/Title VI Coordinator at 740-342-2810. Once completed, return a signed and dated copy to:

Leslie Finck, Chief of Staff
499 N. State Street, New Lexington, Ohio 43764

Note: The following information is necessary to assist us in processing your complaint. Should you require any assistance in completing this form, please call 740-342-2810.

Please check one of the following below:

ADA Complaint Title VI Complaint

Part I.

Name

Address

Telephone

Email Address

Additional Formats Needed:

Other format needed

Part II.

Are you filing this complaint on your own behalf?

Yes – Proceed to Part III No – Please provide the name of and your relationship with this person

Name of Individual

Your Relationship

Please explain why you have filed for a third party:

Confirm:

I have obtained permission of the aggrieved party to file this form on his or her behalf. I have not confirmed permission to file this form on behalf of the aggrieved party.

Part III.

I believe the discrimination I experienced was based on:

Other basis

Date of the alleged discrimination

Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses.

Part IV.

Have you previously filed an ADA and/or Title VI complaint with this agency?

Yes No

Part V.

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:

Please provide the contact information for a person at the agency or court where the complaint was filed:

Name

Title

Agency

Address

Telephone

Email

Part VI.

Name of agency complaint is against

Contact person

Title

Telephone number

Important Notice: To protect your rights, your complaint must be filed within 180 days following the date of the alleged discrimination. Failure to file within 180 days may result in dismissal of the complaint. You may attach any additional written materials or other information that you think is relevant to your complaint to this form.

Signature and date required below.

Signature of Person Filing Complaint

Date

Return to

Leslie Finck, Chief of Staff
499 N. State Street, New Lexington, Ohio 43764
740-342-2810