Title VI Complaint Form

Broward County Board of County Commissioners
Transportation Department – Transit Division

COMPLAINT OF TITLE VI DISCRIMINATION

The Broward County Transit Division is committed to ensuring that no person is excluded from participation in or denied the benefits of its services on the basis of race, color, or national origin, consistent with Title VI of the Civil Rights Acts of 1964, as amended.

Any person who believes that he or she, individually, or as a member of any specific class of persons, has been subjected to discrimination under Title VI, on the basis of race, color, or national origin, may file a written complaint with the Broward County Transit Division.

In order to process your complaint, please fill out the attached form. If you need help in completing this form, please call the Title VI Coordinator at 954-357-8481. The completed form can be returned to:

Broward County Transit Division
Attention: Title VI Coordinator – Safety and Compliance Manager
1 North University Drive, Suite 3100A
Plantation, FL 33324
Telephone: (954) 357-8481
TTY: (954) 357-8302

LANGUAGE TRANSLATION SERVICE AVAILABLE
NOTE:  If you require this Title VI Complaint Form to be translated into another language, please click on “Google Translate” at the top right corner of this web page and select the appropriate language for your translation.

SERVICO DE TRADUCCIÓN LENGUA DISPONIBLE
NOTA: Si usted require de este Formulario de Queja del Titulo VI de ser traducido a otro idoma, por favor haga clic en cualquiera de “Google Translate” en la esquina superior derecha de esta pàgina web y seleccionar el idioma.

LANG TRADIKSYON SÈVIS KI DISPONIB
REMAK: Si w mande pou s a Tit VI Fòm Plent dwe tradui nan yon lòt lang, tanpri klike sou swa “Google Translate” nan kwen paj sa a web tèt dwat epi chwazi lang ki apwopriye a pou tradiksyon ou.

  1. Complainant Information:
    Name (First, Last Name) ________________________________________________________________
    Street Address: ________________________________________________________________
    City, State, Zip Code: ________________________________________________________________
    Telephone: ________________________________________________________________
    Email Address: ________________________________________________________________

  2. Person discriminated against (if someone other than the complainant):
    Name: ________________________________________________________________
    Street Address: ________________________________________________________________
    City, State, Zip Code: ________________________________________________________________
    Telephone: ________________________________________________________________
    Email Address: ________________________________________________________________

  3. Are you represented by an attorney for this complaint?
    Yes_______ No______
    If yes, please complete the following:
    Attorney’s Name: ________________________________________________________________
    Street Address: ________________________________________________________________
    City, State, Zip Code: ________________________________________________________________
    Telephone: ________________________________________________________________

  4. Names and contact information of witnesses:
    ___________________________________________________________________
    ___________________________________________________________________
    ___________________________________________________________________

  5. Which of the following best describes the reason for the alleged discrimination? (Check one or more)
    Race__________
    Color__________
    National Origin, including Limited English Proficiency__________

  6. Please describe the alleged discrimination incident:
    Date of incident: ________________________________________________________________________
    Time of day: __________________________________________________________________________
    Location: _____________________________________________________________________________
    Route number (if applicable): ___________________ Bus number (if applicable): ____________________

    Please explain what happened and who you believe was responsible. Please provide as much detail as possible.
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  7. Have you filed a complaint of the alleged discrimination with any other federal, state, or local agencies; or with a state or federal court?
    Yes______ No______
    If yes, check all that apply:
    Federal________ Federal Court________ State ________ State Court ________ Local Court _______
    Please provide the name of the Agency where you filed your complaint.
    Agency Name: _____________________________________________________________________________
    Contact Person: ____________________________________________________________________________
    Telephone: ________________________________________________________________________________


I affirm that I have read the above charge and that it is true to the best of my knowledge, information, and belief.

____________________________________________
Signature of Complainant

______________________
Date

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