DTSC Form 1443 "Complaint Form for Denial of Services" - California

This version of the form is not currently in use and is provided for reference only.
Download this version of DTSC Form 1443 for the current year.

What Is DTSC Form 1443?

This is a legal form that was released by the California Department of Toxic Substances Control - 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 October 12, 2006;
  • The latest edition provided by the California Department of Toxic Substances Control;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DTSC Form 1443 by clicking the link below or browse more documents and templates provided by the California Department of Toxic Substances Control.

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Download DTSC Form 1443 "Complaint Form for Denial of Services" - California

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State of California – California Environmental Protection Agency
Department of Toxic Substances Control
Complaint Form for Denial of Services
If you believe that you, another person, or group of individuals have been discriminated against because of your race, color,
national origin, religion, age, sex, or disability by DTSC or by any other person or business that receives either federal or
DTSC financial assistance, you can file this complaint with DTSC’s Office of Civil Rights, located at 1001 I Street, Sacramento,
CA 95814, telephone number (916) 324-6546, facsimile number (916) 322-2844.
Please read this form carefully and try to answer all questions that may apply to your situation. Attached to this Complaint Form
is a Fact Sheet entitled “How to File a Title VI Discrimination Complaint with DTSC’s Office of Civil Rights” that acts as a guide
for filling out this Complaint form.
If you have any documents that support your complaint, please attach them to this Complaint Form.
1. COMPLAINANT INFORMATION:
Name
Home Address
Work Telephone Number
E-Mail Address
Daytime Telephone Number
(if different)
2. PERSON(S) OR ENTITY DISCRIMINATED AGAINST IF DIFFERENT THAN ABOVE:
Name
Home or Business Address
Work Telephone Number
E-Mail Address
Daytime Telephone Number
(if different)
3. PERSON, UNIT, DIVISION, or COMPANY THAT DISCRIMINATED:
Unit, Division or Company
Address
Telephone Number
Individual Names (if known)
E-Mail Address (if known)
4. What happened to you? How were you discriminated, harassed, or retaliated against? If you need additional space,
please use additional paper.
DTSC 1443 (10/12/2006)
Page 1 of 3
State of California – California Environmental Protection Agency
Department of Toxic Substances Control
Complaint Form for Denial of Services
If you believe that you, another person, or group of individuals have been discriminated against because of your race, color,
national origin, religion, age, sex, or disability by DTSC or by any other person or business that receives either federal or
DTSC financial assistance, you can file this complaint with DTSC’s Office of Civil Rights, located at 1001 I Street, Sacramento,
CA 95814, telephone number (916) 324-6546, facsimile number (916) 322-2844.
Please read this form carefully and try to answer all questions that may apply to your situation. Attached to this Complaint Form
is a Fact Sheet entitled “How to File a Title VI Discrimination Complaint with DTSC’s Office of Civil Rights” that acts as a guide
for filling out this Complaint form.
If you have any documents that support your complaint, please attach them to this Complaint Form.
1. COMPLAINANT INFORMATION:
Name
Home Address
Work Telephone Number
E-Mail Address
Daytime Telephone Number
(if different)
2. PERSON(S) OR ENTITY DISCRIMINATED AGAINST IF DIFFERENT THAN ABOVE:
Name
Home or Business Address
Work Telephone Number
E-Mail Address
Daytime Telephone Number
(if different)
3. PERSON, UNIT, DIVISION, or COMPANY THAT DISCRIMINATED:
Unit, Division or Company
Address
Telephone Number
Individual Names (if known)
E-Mail Address (if known)
4. What happened to you? How were you discriminated, harassed, or retaliated against? If you need additional space,
please use additional paper.
DTSC 1443 (10/12/2006)
Page 1 of 3
State of California – California Environmental Protection Agency
Department of Toxic Substances Control
5. Why do you believe you are being discriminated, harassed, or retaliated against? For example, do you believe that what
has happened to you or is happening to you is because of your race, national origin, color, religion, sex, age, or disability.
Or do you believe that what has happened or is happening to you is because of something else? Please use additional paper
if you need to fully explain.
6. Who witnessed or has knowledge of the alleged act of discrimination, harassment, or retaliation that you are complaining
about? Please list the names of any and all witnesses to the discrimination, harassment, or retaliation. Please use additional
paper if you need to.
7. When did the last act of discrimination, harassment, or retaliation occur? Please be specific on this date, and indicate the
earliest date of the discrimination and the most recent date of the discrimination.
DTSC makes every effort to protect confidentiality in any investigation, but cannot guarantee absolute confidentiality. The right
to due process and equitable treatment for all parties involved requires DTSC to interview many individuals in its investigation.
Confidentiality will be protected and honored to as great a degree as is legally possible. However, anonymity and complete
confidentiality cannot be guaranteed once a complaint is made or unlawful behavior is made known to DTSC. It is important
that you keep the proceedings of any interview with you strictly confidential. The complaint files will be maintained in confidence
to the fullest extent of the law.
ASSURANCE AND SIGNATURE
I affirm that the above information is true to the best of my knowledge, information, and belief.
Signature: ____________________________
Date:
DTSC 1443 (10/12/2006)
Page 2 of 3
State of California – California Environmental Protection Agency
Department of Toxic Substances Control
How to File a Discrimination Complaint for Exclusion
or Denial of Services
DTSC is committed to ensuring that no person is excluded from participation in, or denied the benefits of its services on the
basis of race, ancestry, color, marital status, national origin, political affiliation, religion, sex, sexual orientation, age, or
disability.
Therefore, if you believe that you have been subjected to discrimination under Title VI of the 1964 Civil Rights Act or
Government Code section 11135 by DTSC, you may file a complaint with DTSC’s Office of Civil Rights (OCR).
You must file your discrimination complaint within one year of the alleged discrimination. However, if you do not discover facts
about a discriminatory practice until after the expiration of the one-year filing period, you may have an additional 90 days to file
a complaint. The address and telephone number for DTSC’s OCR is listed in the heading of the Complaint Form.
The OCR needs certain information to investigate your complaint. Consequently, please make sure you carefully follow the
instructions below for filing out your complaint. The instruction numbers match the numbers in the Discrimination Complaint
Form.
1.
,
Under Complainant Information
please set forth your legal name; home address; home telephone number; e-
mail if you have one; and, a daytime phone number where you can be reached.
2.
Under Person(s) or Entity Discriminated Against If Different Than Above, please set forth the name; address;
telephone numbers; and, e-mail if you know it, of the person or entity that you believe has been discriminated
against.
3.
Under Person, Unit, Division, or Company That Discriminated, please set forth as much information you have
concerning the entity or individual that you feel committed the discrimination.
4.
Under What happened to you, please provide in succinct detail each incident that you believe showed that:
a.
You were excluded from participation in the federally funded or state program or activity;
b.
You were denied benefits from the federally funded or state program or activity; or,
c.
You were subjected to discrimination in a federally funded or state program or activity.
5.
Under Why do you believe you were excluded, denied the benefits, or subjected to discrimination, both Title VI of
the 1964 Civil Rights Act and Government Code section 11135 prohibit the exclusion, denial of benefits or being
subjected to discrimination because of the person’s race, ancestry, color, marital status, national origin,
political affiliation, religion, sex, sexual orientation, age, or disability. For the OCR to investigate your
complaint, you must provide a cause for the alleged treatment. For example, “DTSC did not investigate my
contamination complaint because of my national origin.” In this example, the alleged reason for being denied
DTSC’s enforcement services is because of the individual’s national origin.
6.
Under Who witnessed or has knowledge of the exclusion, denial of services, or discrimination, please set forth the
full name, phone number, e-mail of the individual that may have some knowledge regarding your allegations.
7.
Under When did the last act of exclusion, denial of services, or discrimination occur, please set forth the earliest
date of these actions and the most recent action of exclusion, denial of services, or discrimination.
DTSC 1443 (10/12/2006)
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