Outreach & Escort, Inc. (OUTREACH)

TITLE VI COMPLAINT FORM



Mr. Alan Yonemura, Title VI Administrator

OUTREACH Administration

2221 Oakland Rd., Suite 200

San Jose, California 95131

Phone: 408-678-8585

Email: alany@outreach2.org

 

Section I

 

Name:                                                                                                                 

Address:                                                                                                             

 

Telephone Numbers:

(Home or Cell)                                               (Work)                                         

Email Address                                                                                                    


Accessible Format Requirements?

Large Print:                                           Audio tape:                                          

 

TDD:                                                              Other:                                            

The Federal Transit Administration (FTA) 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 FTA compliant investigation process, we analyze the complainant’s allegations for possible Title VI and related deficiencies by the transit provider.  If deficiencies are identified, they are presented to the transit provider and assistance is offered to correct the inadequacies within a predetermined timeframe.  FTA may also refer the matter to the U.S. Department of Justice for enforcement.


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 FTA?

 

          Yes __________          No ____________

If yes, what was your FTA Complaint Number?  _____________________

(Note:  This information is needed for administrative purposes; the same complaint number may be assigned to the new complaint.)


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

Transit Provider:________   Department of Transportation:  ________

Department of Justice:  _________        Other:  __________________      

Equal Employment Opportunity Commission:  ____________________


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, parties defer to the decision of the court.)





Section IV

Name of public transit or paratransit provider 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 transit/paratransit provider?

          Yes __________          No ____________

May we release a copy of your identity to the transit/paratrasnit provider?

          Yes __________          No ____________


Please sign here:  ______________________________  Date:  ________

(Note:  A signature is required for complaint acceptance.)

 

 

 


COMPLAINT FORM

Mr. Alan Yonemura, Title VI Administrator

OUTREACH Administration

2221 Oakland Rd., Suite 200

San Jose, California 95131

Phone: 408-678-8585

Email: alany@outreach2.org


Santa Clara Valley Transportation Authority (VTA)

Name: Title VI Coordinator

Santa Clara Valley Transportation Authority

3331 North First Street, Bldg. B

San Jose, California 95134-1906

Phone: 408-321-5571

 

 

California Department of
Transportation
Civil Rights, Equal Employment
Opportunity Program
700 N. 10th Street

Suite 102B

Sacramento, Ca. 95814
Phone: 1-916-324-9461

 

 

Federal Transit Administration

Office of Civil Rights

Attention: Complaint Team

1200 New Jersey Ave., SE

Washington, DC 20590
Phone: 1-888-446-4511



Federal Highway Administration

Washington DC Office

Civil Rights Program/Title VI
1200 New Jersey Ave., SE
8th Floor E81-105
Washington DC
Phone: 1-202-336-0693
Fax: 1-202-366-1599