Outreach & Escort, Inc. (OUTREACH)
TITLE VI COMPLAINT FORM
Mr. Paul Tatsuta
OUTREACH Administration
926 Rock Ave., Suite 10
San Jose, California 95131
Phone: 408-436-2865, Ext. 264
Fax: 408-382-0470
Email: bob@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. Paul Tatsuta
OUTREACH Administration
926 Rock Ave., Suite 10
San Jose, California 95131
Phone: 408-436-2865, Ext. 264
Fax: 408-382-0470
Email: bob@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
|
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 Phone: 916-324-1811 |
Federal Highway Administration Sacramento Office Civil
Rights Program/Title VI Program Coordinator |