Full Text
Discrimination Complaint Form Revised 11/2020 City of Woodburn Discrimination Complaint Form Name: Address: City: State: Zip Code: Telephone Number: Were you discriminated against because of your: Race/Ethnicity National Origin Gender Disability To your best recollection, date and time of alleged incident: In your own words, please describe the alleged discrimination. Explain what happened and what policy, program, activity or person you believe was discriminatory. Indicate who was involved and if applicable, the transit route and vehicle. Be sure to include the names and contact information of any witnesses. If more space is needed, please use additional pages. ---PAGE BREAK--- Discrimination Complaint Form Revised 11/2020 Have you already tried to resolve the issue through a grievance process or some other method? Yes No What type of corrective action or resolution would you like to see taken? Have you filed this complaint with any other federal, state or local agency or with any court? Yes No If yes, check and identify all that apply: Federal Agency Federal Court State Agency State Court Local Agency Please provide information for a contact person at the Agency or Court where the complaint was filed. Name: Address: City, State, & Zip Code: Telephone Number: ---PAGE BREAK--- Discrimination Complaint Form Revised 11/2020 Please sign below (we cannot accept unsigned complaints). You may attach any additional written materials or other information you believe is relevant to your complaint. Signature Date Please mail this form to: Human Resources Director City of Woodburn 270 Montgomery St Woodburn, OR 97071 Or email to: [EMAIL REDACTED] Or fax to: [PHONE REDACTED] TTY Statewide Toll Free Relay: (800) 735-1232 SIGN