Form DTSC1443 "Civil Rights Complaint Form" - California

What Is Form DTSC1443?

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 March 29, 2018;
  • 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;

Download a printable version of Form DTSC1443 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 Form DTSC1443 "Civil Rights Complaint Form" - California

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State of California - California Environmental Protection Agency
Department of Toxic Substances Control
DTSC 1443 (03-29-2018)
HOW TO FILE A CIVIL RIGHTS COMPLAINT WITH DTSC’S
OFFICE OF CIVIL RIGHTS
DTSC is committed to ensuring that no person is excluded from participation in, or denied
the benefits of its services on the basis of sex, race, color, religion, ancestry, national
origin, ethnic group identification, age, mental disability, physical disability, medical
condition, genetic information, marital status, or sexual orientation.
Therefore, if you believe that you or someone else has been subjected to discrimination
under Title VI of the 1964 Civil Rights Act or Government Code section 11135 by DTSC,
its contractors, grantees, or other funding recipients, 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. Please note, you may file a complaint
anonymously but that doing so may reduce DTSC’s ability to accept and/or fully
investigate your claim.
Under Person, Unit, Division, or Company That Discriminated, please set
forth as much information you have concerning the entity or individual that you
believe committed the discrimination.
Under Third Party Discriminated Against, please set forth the information
about the person(s) who was directly subject to the behavior you believed to be
discriminatory. This section only needs to be filled out if your complaint is based
on actions towards someone other than yourself.
2. Under What happened, please provide in succinct detail each incident that you
believe showed that:
DTSC 1443 (03/29/2018)
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State of California - California Environmental Protection Agency
Department of Toxic Substances Control
DTSC 1443 (03-29-2018)
HOW TO FILE A CIVIL RIGHTS COMPLAINT WITH DTSC’S
OFFICE OF CIVIL RIGHTS
DTSC is committed to ensuring that no person is excluded from participation in, or denied
the benefits of its services on the basis of sex, race, color, religion, ancestry, national
origin, ethnic group identification, age, mental disability, physical disability, medical
condition, genetic information, marital status, or sexual orientation.
Therefore, if you believe that you or someone else has been subjected to discrimination
under Title VI of the 1964 Civil Rights Act or Government Code section 11135 by DTSC,
its contractors, grantees, or other funding recipients, 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. Please note, you may file a complaint
anonymously but that doing so may reduce DTSC’s ability to accept and/or fully
investigate your claim.
Under Person, Unit, Division, or Company That Discriminated, please set
forth as much information you have concerning the entity or individual that you
believe committed the discrimination.
Under Third Party Discriminated Against, please set forth the information
about the person(s) who was directly subject to the behavior you believed to be
discriminatory. This section only needs to be filled out if your complaint is based
on actions towards someone other than yourself.
2. Under What happened, please provide in succinct detail each incident that you
believe showed that:
DTSC 1443 (03/29/2018)
Page 1 of 5
a. Someone (you or someone else) was excluded from participation in the
federally funded or state program or activity;
b. Someone (you or someone else) was denied benefits from the federally
funded or state program or activity; or,
c. Someone (you or someone else) was subjected to discrimination in a
federally funded or state program or activity.
3. Under Why, please provide in succinct detail why you believe, or someone else,
was excluded, denied benefits, or subjected to discrimination, as prohibited by
Title VI of the 1964 Civil Rights Act and/or Government Code section 11135.
Those laws prohibit the exclusion, denial of benefits or being subjected to
discrimination because of the person's actual or perceived sex, race, color,
religion, ancestry, national origin, ethnic group identification, age, mental
disability, physical disability, medical condition, genetic information,
marital status, or sexual orientation. A complaint may also be filed if you feel
you or someone else has been discriminated against based on an association
with an individual with an actual or perceived protected characteristic. For the
OCR to investigate your complaint, you must provide a motivating factor 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.
4. Under Who, please set forth the full name, phone number, e-mail of any
individual that may have some knowledge regarding your allegations.
5. Under When, please set forth the earliest date of these actions and the most
recent action of exclusion, denial of services, or discrimination.
DTSC 1443 (03/29/2018)
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State of California - California Environmental Protection Agency
Department of Toxic Substances Control
DTSC 1443 (03-29-2018)
CIVIL RIGHTS COMPLAINT FORM
This form should be used by members of the public to file a complaint of discrimination
against the California Department of Toxic Substance Control (DTSC), its contractors,
grantees, or other funding recipients that an individual believes occurred during the
administration of DTSC’s programs and services offered to the public. All complaints
must be filed with DTSC located at 1001 I Street, Sacramento, CA 95814 –Attention:
Civil Rights Complaint, telephone number (916) 324-3095, facsimile number (916) 322-
3111.
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 Civil
Rights 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:
Home
Address
Name
Work Telephone
Number
E-Mail Address
Daytime Telephone
Number (if different)
'
2. PERSON, UNIT, DIVISION, or COMPANY THAT DISCRIMINATED:
Telephone Number (if
known)
Unit, Division or
Address (if known)
Company
E-Mail Address (if known)
Individual Names
(if known)
DTSC 1443 (03/29/2018)
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3. INFORMATION ON THIRD PARTY DISCRIMINATED AGAINST (IF
APPLICABLE):
Telephone Number (if
known)
Name
Address (if known)
Company
E-Mail Address (if known)
(if known)
4. What happened? How were you, or someone else, discriminated, harassed, or
retaliated against? If you need additional space, please use additional paper.
5. Why do you believe you, or someone else, are being discriminated, harassed, or
retaliated against? For example, do you believe that what has happened or is
happening is because of your, or someone else’s, actual or perceived sex, race,
color, religion, ancestry, national origin, ethnic group identification, age, mental
disability, physical disability, medical condition, genetic information, marital
status, or sexual orientation? Or do you believe that what has happened or is
happening is because of something else? Please use additional paper if you
need to fully explain.
DTSC 1443 (03/29/2018)
Page 4 of 5
6. Who other than you 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 as specific as possible, 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.
Date
Name
Signature
DTSC 1443 (03/29/2018)
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