"Language Access Complaint Form" - California

Language Access Complaint Form is a legal document that was released by the California Secretary of State - a government authority operating within California.

Form Details:

  • Released on July 1, 2015;
  • The latest edition currently provided by the California Secretary of State;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the California Secretary of State.

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Download "Language Access Complaint Form" - California

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STATE OF CALIFORNIA
SECRETARY OF STATE
Language Access Complaint Form
The Secretary of State’s Office is fully committed to ensuring that all persons accessing its services are
provided these services in an appropriate and timely manner. The Dymally-Alatorre Bilingual Services Act
(California Government Code sections 7290-7299.8) requires the Secretary of State’s office to provide effective
communication to all people utilizing public services. If you feel the Secretary of State’s office was unable to
serve you because of a language barrier (limited-English proficiency) or other communication differences, the
Secretary of State’s office may be able to provide additional communication assistance that will assist you with
the information or services you have requested.
Please use this form to report any language access complaint you have encountered at the Secretary of
State’s office. Please submit this form and any supporting documentation to: Secretary of State, Human
th
Resources Office, 1500 11
Street Room 475, Sacramento, CA 95814, Attention: Equal Employment
Opportunity Officer. You may also fax the form and supporting documentation to (916) 653-8024.
SECTION A – CUSTOMER INFORMATION
Name:
Language Spoken:
Address:
Phone Number:
Email:
SECTION B – COMPLAINT DETAILS
Date of Incident:
Location of office:
Division/Unit
Language Access Issues:
(Check all that apply)
 Lack of assistance by agency staff in non-English language
 Lack of translated materials in non-English language
 Interpreter available was not skilled/knowledgeable
 Translations were not accurate
 Other (explain)___________________________________________
What language did you need assistance with?
 Cantonese
 Hmong
 Mandarin
 Russian
 Spanish
 Tagalog
 Other (explain)___________________________________________
Rev 07/2015
STATE OF CALIFORNIA
SECRETARY OF STATE
Language Access Complaint Form
The Secretary of State’s Office is fully committed to ensuring that all persons accessing its services are
provided these services in an appropriate and timely manner. The Dymally-Alatorre Bilingual Services Act
(California Government Code sections 7290-7299.8) requires the Secretary of State’s office to provide effective
communication to all people utilizing public services. If you feel the Secretary of State’s office was unable to
serve you because of a language barrier (limited-English proficiency) or other communication differences, the
Secretary of State’s office may be able to provide additional communication assistance that will assist you with
the information or services you have requested.
Please use this form to report any language access complaint you have encountered at the Secretary of
State’s office. Please submit this form and any supporting documentation to: Secretary of State, Human
th
Resources Office, 1500 11
Street Room 475, Sacramento, CA 95814, Attention: Equal Employment
Opportunity Officer. You may also fax the form and supporting documentation to (916) 653-8024.
SECTION A – CUSTOMER INFORMATION
Name:
Language Spoken:
Address:
Phone Number:
Email:
SECTION B – COMPLAINT DETAILS
Date of Incident:
Location of office:
Division/Unit
Language Access Issues:
(Check all that apply)
 Lack of assistance by agency staff in non-English language
 Lack of translated materials in non-English language
 Interpreter available was not skilled/knowledgeable
 Translations were not accurate
 Other (explain)___________________________________________
What language did you need assistance with?
 Cantonese
 Hmong
 Mandarin
 Russian
 Spanish
 Tagalog
 Other (explain)___________________________________________
Rev 07/2015
STATE OF CALIFORNIA
SECRETARY OF STATE
Language Access Complaint Form
SECTION B – COMPLAINT DETAILS (CONT.)
Brief Description of Complaint: (Attach additional pages if needed)
SECTION C – FORM ASSISTANCE
 Yes (input information below)
Did someone assist you in completing this form?
 No
Name:
Organization:
Phone Number:
Email:
SECTION D – DEPARTMENTAL USE ONLY
Date & Time Received:
Action Taken:
Contact Person:
Tracking Number:
Rev 07/2015
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