Outreach & Escort, Inc. (OUTREACH)

TITLE VI COMPLAINT FORM

Mr. Paul Tatsuta

OUTREACH Administration

PO Box 640910
San Jose, California 95164
Phone: 408-436-2865, Ext. 264
Fax: 408-382-0470
Email: Pault@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
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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:


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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.)
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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.)
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COMPLAINT FORM

Paul Tatsuta
OUTREACH Administration
PO Box 640910
San Jose, California 95164
Phone: 408-436-2865, Ext. 264
Fax: 408-382-0470
Email: pault@outreach2.org
Santa Clara Valley Transportation Authority (VTA) Name: Ms. Mitsuno Baumeister, Title VI Coordinator Office: Employee Relations Department
Santa Clara Valley Transportation Authority
3331 North First Street, Bldg. B San Jose, California 95134-1906
Phone: 408-321-5571
Caltrans District 4
Title VI Liaison
111 Grand Ave., MS 6A Oakland, California 94613
Phone: 510-286-6169
Fax: 510-286-5234
Federal Transit Administration Title VI Program Coordinator East Building, 5th Floor – TCR
1200 New Jersey Ave., SE Washington, DC 20590
Caltrans Headquarters
Office of Business & Economic
Opportunities
1823 14th Street, MS 79
Sacramento, California 95811
Phone: 916-324-1811
Federal Highway Administration
Sacramento Office
Civil Rights Program/Title VI Program Coordinator
650 Capital Mall, Suite 4-1000
Sacramento, California 95814
Phone: 916-498-5001
Fax: 916-498-5008
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