Full Text
1 Complainants are encouraged, but not required, to use the following complaint form when filing a complaint with City of Blackfoot or ITD. At a minimum, each complaint should contain a written explanation of the alleged discrimination, complainant’s contact information, the basis of the complaint race, color, national origin), the names of specific individuals or agencies involved, sufficient information to understand the facts that led the complainant to believe that discrimination occurred in a program or activity that receives Federal financial assistance, and date(s) of the alleged discrimination. FHWA Title VI Complaint Form Contact information of person completing this complaint: Phone: Email: Basis of Complaint (circle all that apply): Race Color National Origin Who discriminated against you? Name of How were you discriminated against? (Please provide specific details - attach additional pages if more space is needed) Where did the discrimination occur? ---PAGE BREAK--- 2 Dates and times discrimination occurred? Were there any other witnesses to the discrimination? Name Organization/Title Work Telephone Home Telephone How would you like to see this situation resolved? Have you filed your complaint, grievance, or lawsuit with any other agency or court? Who When Status (pending, resolved, etc.) Result, if known Complaint number, if known Do you have an attorney in this matter? ---PAGE BREAK--- 3 Complaints may also be filed directly with the following agencies: Idaho Transportation Department Office of Civil Rights 11331 W. Chinden Blvd Boise, ID 83714 [EMAIL REDACTED] Phone: (208) 334-8884 Federal Highway Administration, Idaho Division 3050 Lakeharbor Lane #126 Boise, ID 83703 [EMAIL REDACTED] Phone: (208) 334-1843 Federal Highway Administration U.S. Department of Transportation Office of Civil Rights 1200 New Jersey Avenue, SE 8th Floor E81-105 Washington, DC 20590 [EMAIL REDACTED] Phone: (202) 366-0693 Fax: (202) 366-1599 City of Blackfoot Title IV Coordinator 157 N Broadway St Blackfoot, ID83221 (208)785-8600 x-7 (208)785-8602 fax