Oregon Department of Environmental Quality: Title VI Civil Rights Complaint Form

Title VI Civil Rights Complaint Form

Title VI of the Civil Rights Act of 1964 states "No person in the United States shall, on the grounds of race, color, or national origin, be excluded from participation in, denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance." - Title 42 Section 200d.

To request assistance with translation, interpretation, or alternative formats of this form, please contact us at deqinfo@deq.oregon.gov or call 503-229-5696 or 800-452-4011 (toll-free in Oregon), TTY: 771.

If you believe you have been discriminated against at the Oregon Department of Environmental Quality or one of its vendors, please utilize this online form to submit a complaint. If you need assistance in filling out this form, please contact Nancy Dickison at 503-728-8070 or email her at deqinfo@deq.oregon.gov.

Please note that with the exception of personally identifying information, the complaint form is not confidential and DEQ may be required to disclose this information upon request.

You may submit this complaint anonymously. If you do, please provide as much information as you can so that we may conduct a thorough investigation.

Form fields are optional unless marked with a red asterisk

Complainant (person completing this report):

Name

Address

Include city, state, and zip code

Phone Number

Other person(s) discriminated against (other than complainant):

Name #1

Address #1

Include city, state, and zip code

Phone Number #1

Name #2

Address #2

Include city, state, and zip code

Phone Number #2

Name #3

Address #3

Include city, state, and zip code

Phone Number #3

What was the alleged discrimination based on?

Select all that are applicable.

Race or Color

Disability

Limited English Proficiency

National Origin

Low Income

Sex

Other

Date & location of alleged discrimination:

Date of Alleged Discrimination

Location of Alleged Discrimination

Agency or person(s) responsible for the alleged discrimination:

Supply as much information as is available.

Name #1

Agency or Business #1

Address #1

Include city, state, and zip code

Phone Number #1

Name #2

Agency or Business #2

Address #2

Include city, state, and zip code

Phone Number #2

Name #3

Agency or Business #3

Address #3

Include city, state, and zip code

Phone Number #3

Other identifying information (vehicle number, badge ID)

Describe the alleged discrimination:

Explain what happened and whom you believe was responsible.

Please describe

Names and contact information of any person(s) who may have knowledge of the alleged discrimination:

Name #1

Address #1

Phone Number #1

Name #2

Address #2

Phone Number #2

Name #3

Address #3

Phone Number #3

In your opinion, what resolution(s) would you consider acceptable in the outcome of this complaint?

Please describe

Upload files:

You may attach written materials or other supporting information that you think is relevant to your complaint.

Up to 30 files may be attached. The total size of all files combined may not exceed 10MB. Acceptable file types are PDFs, Microsoft Word documents, and images.

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Use of personal information

The Department of Environmental Quality will keep the information you provide on this form confidential for the purposes of fulfilling your request. DEQ will also attempt to keep your information confidential if a public records request is filed, in accordance with Oregon’s Public Records Law. If you would prefer to waive this confidentiality, please select that option below.

I choose to waive confidentiality - I have read and understand the above information and authorize the Oregon Department of Environmental Quality (DEQ) to reveal my identity to persons at the organization or institution under investigation. I hereby authorize DEQ to receive material and information about me pertinent to the investigation of my complaint. I understand that the material and information will be use for authorized civil rights compliance and enforcement activities. I further understand that I am not required to authorize this release, and do so voluntarily.

I do not waive confidentiality - I have read and understand the above information and do not want DEQ to reveal my identity to the organization or institution under investigation, or to review, receive copies of, or discuss material and information about me, pertinent to the investigation of my complaint. I understand this is likely to impede the investigation of my complaint and may result in the closure of the investigation.

Complainant Certification

By submitting this online form, I certify that the information contained in this complaint is true and accurate to the best of my knowledge, I further agree that typing my name in the signature box and submitting this report is the equivalent of a manual signature for the purposes of this form.

An email address is NOT REQUIRED in order to submit the form, but it allows DEQ to provide updates on any investigation to the email address provided.

Signature

Signature Date

Note: If preferred, this form may be printed, filled out, and mailed to DEQ, Attn: Nancy Dickison, 700 NE Multnomah St.,Suite 600, Portland, OR 97232