Title VI Complaint Form

Title VI of the Civil Rights Act of 1964, and other related laws and regulations, provide that no
person shall on the grounds of race, color, national origin, sex, age, disability, and income be
excluded from participation in, be denied the benefits of, or otherwise be subjected to
discrimination under any program or activity receiving federal funds.

The purpose of this form is to assist you in filing a complaint with CCATD’s Title VI Coordinator.
You are not required to use this form. A letter containing the same information is sufficient.
However, the information requested must be provided, whether or not this form is used. ADA
assistance is available upon request.

You may file a complaint against the CCATD. All complaints must be filed within 180 days of
the occurrence of the alleged act or a waiver requested as indicated below. You also may file a
complaint directly with the ODOT Office of Civil Rights or the FTA Office of Civil Rights.

Submit the online form here, or print out and send your completed form to the address below:

PDF Version of the Title VI Complaint form.

CCATD: Title VI Complaint Coordinator
2810 Ocean Blvd
Coos Bay, OR 97459

Submitter's Name(Required)

First Last

Submitter's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone

Is the Person(s) discriminated against different from the submitter above?(Required)

Person(s) Discriminated Against, if Different from Above.

First Last

Person(s) Discriminated Against, if Different from Above.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone Number

CCATD Employee that Discriminated Against You:

First Last

Location the Discrimination Occurred:(Required)

Street Address City ZIP / Postal Code

Bus Number or other Identifying Information:

Date the Discrimination Occurred:

Indicate the Reasons You Believe the Discriminatory Action(s) Occurred:

Race/Ethnicity

National Origin

Sex

Religion

Age

Disability

Please explain as clearly as possible what occurred, who was involved, why you believe it occurred, and how you (or another) were discriminated against. Be sure to include how other persons were treated differently than you.

Complaints of discrimination must generally be filed within 180 days of the alleged discrimination. If the most recent date of discrimination listed above is more than 180 days ago, you may request a waiver of the filing requirement. If you wish to request a waiver, please explain why you waited until now to file your complaint.

This field is for validation purposes and should be left unchanged.