Form JUS8864 "Language Barrier Reporting Form (English)" - California

What Is Form JUS8864?

This is a legal form that was released by the California Department of Justice - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2017;
  • The latest edition provided by the California Department of Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form JUS8864 by clicking the link below or browse more documents and templates provided by the California Department of Justice.

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Download Form JUS8864 "Language Barrier Reporting Form (English)" - California

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STATE OF CALIFORNIA
DEPARTMENT OF JUSTICE
LANGUAGE BARRIER REPORTING FORM (ENGLISH)
Page 1 of 2
JUS 8864 (Rev. 11/2017)
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LANGUAGE BARRIER REPORTING FORM (ENGLISH)
Non-Compliance with the Dymally-Alatorre Bilingual Services Act
This form may be translated into another language upon request.
Please contact the Equal Employment Rights and Resolution Office at (916) 210-7580.
California Department of Justice
Office of the Attorney General
Equal Employment Rights and Resolution Office
1300 I Street
Sacramento, CA 95814
(916) 210-7580
If you feel we have been unable to serve you because of language barriers or non-compliance with the Dymally-Alatorre
Bilingual Services Act, the Department of Justice may be able to provide additional assistance in serving your requested
needs.
Please provide the following information and we will attempt to resolve your concern(s) in a timely manner.
First Name:
Last Name:
Address:
City:
Zip Code:
Day Phone:
E-mail:
Name of Program/Unit/Section Contacted:
Phone Number Contacted:
Name of Individual(s) You Spoke With:
Location of Service (address if known):
Date Service Sought:
Please describe the service(s) you sought and any other information that might be helpful in resolving your concerns:
You may file a complaint of lack of adequate access to your language against our department with the State Personnel
Board, 801 Capitol Mall, Sacramento, CA 95814, or the United States Department of Justice, Office of Civil Rights
(U.S. Department of Justice, Civil Rights Division), 950 Pennsylvania Ave., NW, Washington, DC 20530-0001.
STATE OF CALIFORNIA
DEPARTMENT OF JUSTICE
LANGUAGE BARRIER REPORTING FORM (ENGLISH)
Page 1 of 2
JUS 8864 (Rev. 11/2017)
Print Form
Save Form
Reset Form
LANGUAGE BARRIER REPORTING FORM (ENGLISH)
Non-Compliance with the Dymally-Alatorre Bilingual Services Act
This form may be translated into another language upon request.
Please contact the Equal Employment Rights and Resolution Office at (916) 210-7580.
California Department of Justice
Office of the Attorney General
Equal Employment Rights and Resolution Office
1300 I Street
Sacramento, CA 95814
(916) 210-7580
If you feel we have been unable to serve you because of language barriers or non-compliance with the Dymally-Alatorre
Bilingual Services Act, the Department of Justice may be able to provide additional assistance in serving your requested
needs.
Please provide the following information and we will attempt to resolve your concern(s) in a timely manner.
First Name:
Last Name:
Address:
City:
Zip Code:
Day Phone:
E-mail:
Name of Program/Unit/Section Contacted:
Phone Number Contacted:
Name of Individual(s) You Spoke With:
Location of Service (address if known):
Date Service Sought:
Please describe the service(s) you sought and any other information that might be helpful in resolving your concerns:
You may file a complaint of lack of adequate access to your language against our department with the State Personnel
Board, 801 Capitol Mall, Sacramento, CA 95814, or the United States Department of Justice, Office of Civil Rights
(U.S. Department of Justice, Civil Rights Division), 950 Pennsylvania Ave., NW, Washington, DC 20530-0001.
STATE OF CALIFORNIA
DEPARTMENT OF JUSTICE
LANGUAGE BARRIER REPORTING FORM (ENGLISH)
Page 2 of 2
JUS 8864 (Rev. 11/2017)
Privacy Notice As Required by Civil Code § 1798.17
Language Barrier Reporting (English) - Form JUS 8864
Collection and Use of Personal Information. The Executive Programs in the Department of Justice collects the information
requested on the “Language Barrier Reporting Form (English)”, as authorized pursuant to the Dymally-Alatorre Bilingual
Services Act, Government Code section 7290 et seq. (the Act). The Executive Programs uses this information to further the
intent of the Act to provide effective communication between the state government and the people of this state who are
precluded from utilizing public services because of language barriers, as set forth in Government Code section 7291; and also
to promote compliance with other provisions of the Act under Government Code sections 7292(a) and 7299.4, subsections (a)
and (d). In addition, any personal information collected by state agencies is subject to the limitations found in the Information
Practices Act, Civil Code section 1798 et seq., and state policy. The DOJ's general privacy policy is available at http://oag.ca.
gov/privacy-policy.
Providing Personal Information. Completing this form, by providing your personal information and a description of the
services you sought and the language barrier that impeded your receipt of those services, is voluntary. However, if you do not
give identification and contact information, and/or you do not provide information about the services that you sought and how
your receipt of those services was impeded by a language barrier, then the DOJ may not be able to resolve your particular
language barrier concerns and provide the requested services.
Access to Your Information. If you request to do so, you are permitted to inspect all the personal information in any records
about you maintained by the DOJ, as provided under the Information Practices Act and other applicable laws. See below for
contact information.
Possible Disclosure of Personal Information. In order to provide effective communication between the Executive Programs
and members of the public who are impeded from utilizing the DOJ's public services because of a language barrier, the Equal
Employment Rights & Resolution Office may need to share the personal information you give with other units within the DOJ.
The information you provide may also be disclosed in the following circumstances:
o With other persons or agencies where necessary to perform their legal duties, and their use of your information is
compatible and complies with state law; such as for licensing, certification, or regulatory purposes.
o To another government agency as required by state or federal law.
Contact Information. For questions about this notice or how to access your personal information maintained in records about
you, you may contact the Equal Employment Opportunity Officer, P.O. Box 944255, Sacramento, CA 94244,
EERRForms@doj.ca.gov, (916)210-7580.
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