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Title VI Complaint Format

Federal Railroad Administration
Office of Civil Rights
Title VI Complaint Template

 

The Federal Railroad Administration (FRA) Office of Civil Rights is responsible for civil rights compliance and monitoring, which includes ensuring that providers of public transportation properly abide by Title VI of the Civil Rights Act of 1964, Executive Order 12898, “Federal Actions To Address Environmental Justice in Minority Populations and Low Income Populations,” and the Department of Transportation’s Guidance to Recipients on Special Language Services to Limited English Proficient (LEP) Beneficiaries.

In the FRA complaint investigation process, we analyze the complainant's allegations for possible Title VI and related deficiencies by the recipient. If deficiencies are identified they are presented to the recipient and assistance is offered to correct the inadequacies within a predetermined timeframe. FRA also may refer the matter to the U.S. Department of Justice for enforcement.

 

Section I

Name:_________________________________________

Address:_______________________________________

Telephone Numbers:

(Home)_______________(Work)___________________

Electronic Mail Address:___________________________

Accessible Format Requirements?

Large Print _______ Audio tape _____

TDD ___________ Other________________________________________

 

Section II

Are you filing this complaint on your own behalf?

Yes ____ No ____

[If you answered "yes" to this question, go to Section III.]

If not, please supply the name and relationship of the person for whom you are complaining: _________________________________________________

Please explain why you have filed for a third party. _______________________________

______________________________________________________________________

Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.

Yes ____ No ____

 

Section III

Have you previously filed a Title VI complaint with FRA? Yes____ No___

If yes, what was your FRA Complaint Number? _____________

[Note: This information is needed for administrative purposes; we will assign the same complaint number to the new complaint.]

Have you filed this complaint with any of the following agencies?

Recipient  _____ Department of Transportation ____

Department of Justice_____ Equal Employment Opportunity Commission _____

Other _____________________________________________

Have you filed a lawsuit regarding this complaint? Yes_____ No____

If yes, please provide a copy of the complaint form.

 

Note: This above information is helpful for administrative tracking purposes. However, if litigation is pending regarding the same issues, we defer to the decision of the court.

 

Section IV

Name of entity complaint is against:

_____________________________________________________________________

Contact person: _________________________ Title: __________________________

Telephone number: _____________________________________________________

On separate sheets, please describe your complaint. You should include specific details such as names, dates, times, route numbers, witnesses, and any other information that would assist us in our investigation of your allegations.  Please also provide any other documentation that is relevant to this complaint.

 

Section V

May we release a copy of your complaint to the recipient?

Yes ____ No ____

May we release your identity to the recipient?

Yes ____ No ____

Please sign here: _____________________________________________

Date: ______________

 

Note - We cannot accept your complaint without a signature.

 

You may mail your completed complaint to:

Federal Railroad Administration
Office of Civil Rights

1200 New Jersey Avenue, SE
ROA-10, Mail Stop 5
Washington, DC 20590

OR fax it to:  FRA, OCR at 202-493-6481

OR e-mail it to:  civil.rights@dot.gov

Once your complaint is received, you will receive a letter acknowledging receipt of the complaint.

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    1200 New Jersey Avenue, SE
    Washington, DC 20590
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