Sound Generations Title VI, ADA, and General Complaint Form
Please select the type of complaint you are filing:
Title VI Complaint
Address Line 1
Address Line 2
Accessible format requirements?
Are you filing this complaint on your own behalf?
If no, please supply the name and relationship of the person whose behalf you are filling:
Please explain why you have filed for a third party:
Have you received permission from the third party to the file on their behalf?
Section III: Title VI ONLY
I believe the discrimination I experienced was based on (please check all that apply):
Date of incident:
Please 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 the names and contact information for any witnesses (if known):
Have you previously filed a complaint with this organization?
Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State Court?
If yes, please check all that apply:
Please provide contact information for the agency/court where the complaint was filed.
If you filed with a 2nd agency:
If you filed with a 3rd agency:
Section 4: For ADA or General Complaints
Name of person or program this complaint is against:
For non-Title VI complaints, please use the space below to explain the issue/experience: