Form OBEO-0002 "Title VI and Other Discrimination Complaint Form" - California

What Is Form OBEO-0002?

This is a legal form that was released by the California Department of Transportation - 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 February 1, 2018;
  • The latest edition provided by the California Department of Transportation;
  • 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 fillable version of Form OBEO-0002 by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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Download Form OBEO-0002 "Title VI and Other Discrimination Complaint Form" - California

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
TITLE VI AND OTHER DISCRIMINATION COMPLAINT FORM
Page 1 of 3
OBEO-0002 (REV 02/2018)
Section I - Applicability
Name:
Electronic Mail Address:
Phone Number (Include Area Code):
Work Phone Number (Include Area Code):
Address:
City, State, Zip:
Accessible Format Requirements:
Large Print
TDD
Audio Tape
Other
Are you filing this complaint on your own behalf?
Yes (Go to Section II)
No
If not, please supply the name and relationship
of the person for whom you are complaining:
Briefly and clearly explain why you have filed for a third party.
Section II - Title VI
Discrimination Because of:
Other Areas of Discrimination:
Race
Color
National Origin
Sex
Age
Disability
Retaliation
Name and Position of Person(s) That Discriminated Against You:
Location Including City, State, Zip:
Explain as briefly and clearly as possible what happened, and how you were discriminated against. Include date of alleged discrimination
(Month, Day, Year). Indicate all persons who were involved. Be sure to describe how other persons were treated differently than you. Attach
any written material pertaining to your case.
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
TITLE VI AND OTHER DISCRIMINATION COMPLAINT FORM
Page 1 of 3
OBEO-0002 (REV 02/2018)
Section I - Applicability
Name:
Electronic Mail Address:
Phone Number (Include Area Code):
Work Phone Number (Include Area Code):
Address:
City, State, Zip:
Accessible Format Requirements:
Large Print
TDD
Audio Tape
Other
Are you filing this complaint on your own behalf?
Yes (Go to Section II)
No
If not, please supply the name and relationship
of the person for whom you are complaining:
Briefly and clearly explain why you have filed for a third party.
Section II - Title VI
Discrimination Because of:
Other Areas of Discrimination:
Race
Color
National Origin
Sex
Age
Disability
Retaliation
Name and Position of Person(s) That Discriminated Against You:
Location Including City, State, Zip:
Explain as briefly and clearly as possible what happened, and how you were discriminated against. Include date of alleged discrimination
(Month, Day, Year). Indicate all persons who were involved. Be sure to describe how other persons were treated differently than you. Attach
any written material pertaining to your case.
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
TITLE VI AND OTHER DISCRIMINATION COMPLAINT FORM
Page 2 of 3
OBEO-0002 (REV 02/2018)
The laws prohibit retaliation against anyone because he/she has taken action, or participated in an action, to secure rights protected by these
laws. If you feel you have been retaliated against (separate from the discrimination alleged above), please explain briefly and clearly the
circumstances below. Please explain what actions you took which you believe were the basis for the allegation of retaliation.
What remedy or action, do you seek for the alleged discrimination?
Have you previously filed a complaint with this agency?
Yes
No
Have you filed, or intend to file, a charge or complaint with the following?
U.S. Equal Employment Opportunity Commission
Federal Highway Administration/U.S. Department of Transportation
or
State Court
Federal
Federal Transit Administration/U.S. Department of Transportation
Department of Fair Employment and Housing
If you have already filed a charge or complaint, please provide information about a contact person at the agency/court where the complaint was filed.
Name:
Title:
Agency/Court:
Address:
Telephone Number (Including Area Code):
Date Filed:
Case Number:
Date of Trial/Hearing:
Provide any additional information, including witnesses, that you believe would assist in the investigation.
Signature of Complainant:
Date:
FOR OFFICE USE ONLY
Location:
District/Division:
Case:
Date Complaint Received:
Date Referred:
Processed by:
Referred to:
USDOT
FHWA
OTHER
FTA
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
TITLE VI AND OTHER DISCRIMINATION COMPLAINT FORM
Page 3 of 3
OBEO-0002 (REV 02/2018)
INSTRUCTIONS
Section I
Applicability – The complaint procedures apply to the beneficiaries of Caltrans programs, activities, and services, including but not limited to
the public, contractors, subcontractors, consultants, and other sub-recipients of Federal funds.
All complaints must be in writing and signed by the complainant. Complaints must include the complainant’s name, address, phone
number, and specify all issues and circumstances of the alleged discrimination. In cases where the complainant is incapable of
providing a written statement such as limited English proficient or having a disability, the complainant may be assisted in converting
the verbal into a written complaint.
Section II
Title VI – Any person who believes he/she has been excluded from participation in or denied benefits or services of any program or activity
administered by Caltrans, or its sub-recipients, consultants, and contractors.
Discrimination Because of – Allegations must be based on issues involving race, color, national origin for a Title VI complaint or sex, age,
disability, or retaliation.
Filing Options and Time Limits – The use of the complaint form is not mandatory. You may submit your complaint in any form that includes
your signature. Title VI discrimination complaints may be filed with Caltrans, the Federal Highway Administration, or other agencies that provide
federal financial assistance to Caltrans.
Complaints must be filed no later than 180 days after the date of the alleged act of discrimination or retaliation unless the time for
filing is extended. Failure to supply all information may be grounds for rejecting your complaint.
Submit Complaints – The original-signed complaint form or letter is mailed to:
California Department of Transportation
Office of Business and Economic Opportunity
Attention: Title VI Branch Manager
1823 14th Street, MS 79
Sacramento, CA 95811
Information – Email:
Title.VI@dot.ca.gov
Phone: (916) 324-8379
Website:
http://www.dot.ca.gov/obeo/TitleVI.html
PERSONAL INFORMATION NOTICE
Pursuant to the Federal Privacy Act (Section 552, et seq.) and the Information Practices Act of 1977 (IPA) (Civil Code Sections 1798, et seq.), notice is hereby
given for the request of personal information by this form. The requested personal information is voluntary. The principal purpose of the voluntary information is
to facilitate the processing of this form. The failure to provide all or any part of the requested information may delay processing of this form. No disclosure of
personal information will be made unless permissible under Article 6, Section 1798.24 of the IPA of 1977. Each individual has the right upon request and proper
identification, to inspect all personal information in any record maintained on the individual by an identifying particular.
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
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