HomeMy WebLinkAboutTitle VI Notice and Complaint Form
Notification of Rights Under Title VI
Coordinated Services for the Elderly
The Coordinated Services for the Elderly operates its programs and services
without regard to race, color, or national origin in accordance with Title VI of the
Civil Rights Act of 1964, and related nondiscrimination authorities, any person
who believes she or he has been aggrieved by any unlawful discriminatory practice
under Title VI may file a complaint with the Coordinated Services for the
Elderly.
For more information on the Coordinated Services for the Elderly Title VI
Program, and/or discrimination complaint procedures, contact the Operations
Assistant Director., at (808) 323-4320, email: ead2@hawaiicounty.gov; or visit
our administrative office at West Hawai‘i Civic Center, Building B, 74-5044
Kailua-Kona, HI 96740.
A complainant may file a complaint directly with the State of Hawai‘i Department
of Transportation (HDOT) Office of Civil Rights, ATTN: Title VI Specialist, 200
Rodgers Boulevard, Honolulu HI 96819 or the Federal Transit Administration
(FTA) ATTN: Title VI Program Coordinator, East Building, 5th Floor-TCR 1200
New Jersey Ave., SE Washington DC 20590.
If information is needed in another language contact, Tasha Hoggatt, Equal
Opportunity Officer /ADA Coordinator at (808) 961-8361. Para información en
Español llame: Tasha Hoggatt, Equal Opportunity Officer / ADA Coordinator
at (808) 961-8361.
Discrimination Comp aint Form
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Name:
Address:
Telephone(Home): Telephone(Work):
Electronic Mail Address:
Large Print 0 Audio Tape 0
Accessible Format Requirements? TDD E Other 0
Section II:
Are you filing this complaint on your own behalf? Yes* 0 No 0
*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. El Yes 0 No
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I believe the discrimination I experienced was based on (check all that apply):
Race 0 Color 0 National Origin 0
Date of Alleged Discrimination (Month,Day,Year): Click or tap here to enter text.
Explain as clearly as possible what happened and why you believe you were discriminated
against. Describe all persons who were involved. Include the name and contact information
of the person(s) who discriminated against you (if known) as well as names and contact
information of any witnesses. If more space is need, please use the back of this form.
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Have you previously filed a discrimination complaint with this
agency? CI Yes El No
If yes, please provide any reference information regarding your previous complaint.
Section
Have you filed this complaint with any other Federal, State, or local agency, or with any Federal
or State court?
❑ Yes ❑ No
If yes, name all that apply:
Federal Agency:
Federal Court:
State Court:
State Agency:
Local Agency:
Please provide information about a contact person at the agency/court where the complaint
was filed.
Name:
Title:
Agency:
Address:
Telephone:
Section VI:
Name of agency complaint is against:
Name of person complaint is against:
Title:
Location:
Telephone Number(if available):
You may attach any written materials or other information that you think is relevant to your
Complaint. Your signature and date are required below
Signature Date
12