Sound Generations Title VI, ADA, and General Complaint Form
Please select the type of complaint you are filing:
Please select...
Title VI Complaint
ADA Complaint
General Complaint
Section I:
First Name
Last Name
Phone
Email
Address Line 1
Address Line 2
City
State/Province
Postal Code
Accessible format requirements?
Please select...
Large Print
TDD
Audiotape
Other
Section II:
Are you filing this complaint on your own behalf?
Yes
No
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?
Yes
No
Section III: Title VI ONLY
I believe the discrimination I experienced was based on (please check all that apply):
Race
Color
National Origin
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?
Yes
No
Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State Court?
Yes
No
If yes, please check all that apply:
Federal Agency
state Agency
Federal Court
Local Agency
State Court
Please provide contact information for the agency/court where the complaint was filed.
Name
Title
Agency
Phone
Address
If you filed with a 2nd agency:
Name
Title
Agency
Phone
Address
If you filed with a 3rd agency:
Name
Title
Agency
Phone
Address
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:
Validation:
Signed by:
Date