Form DPR-045 "Language Access Assistance Resolution Form" - California

What Is Form DPR-045?

This is a legal form that was released by the California Department of Pesticide Regulation - 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 1, 2018;
  • The latest edition provided by the California Department of Pesticide Regulation;
  • 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 DPR-045 by clicking the link below or browse more documents and templates provided by the California Department of Pesticide Regulation.

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Download Form DPR-045 "Language Access Assistance Resolution Form" - California

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State of California
Department of Pesticide Regulation
LANGUAGE ACCESS ASSISTANCE RESOLUTION FORM
DPR-045 (Rev. 03/18)
Page 1 of 2
LANGUAGE ACCESS ASSISTANCE RESOLUTION FORM
This form may be used by any member of the public to request language access assistance or file a
complaint regarding an inability to receive services due to a language barrier from the California Department
of Pesticide Regulation (DPR) and any regional DPR offices. For questions related to language access
services or for assistance filing a complaint, please contact the Bilingual Coordinator at (916) 322-4553.
Submit completed form to:
California Department of Pesticide Regulation
Human Resources Branch, Attention: Bilingual Coordinator
1001 I Street, 4
Floor, MS-4B, Sacramento, CA 95814
th
Fax: (916) 445-6416
Email:
BilingualServices@cdpr.ca.gov
Please answer all questions. You may use additional sheets, if needed.
Complainant Information:
This information is required so that we can contact you to assist with resolving your complaint.
Name:
Primary Language:
Email Address:
Mailing Address:
Telephone Number (daytime):
Alternate Number:
Nature of the problem:
[ ] Not provided interpretation services
[ ] Not provided translated materials
[ ] Interpreters or translators not competent
[ ] Unable to access services, programs or activities
[ ] Services not timely
[ ] Lack of signs informing public of language access services
[ ] Other
− CONTINUED ON REVERSE −
State of California
Department of Pesticide Regulation
LANGUAGE ACCESS ASSISTANCE RESOLUTION FORM
DPR-045 (Rev. 03/18)
Page 1 of 2
LANGUAGE ACCESS ASSISTANCE RESOLUTION FORM
This form may be used by any member of the public to request language access assistance or file a
complaint regarding an inability to receive services due to a language barrier from the California Department
of Pesticide Regulation (DPR) and any regional DPR offices. For questions related to language access
services or for assistance filing a complaint, please contact the Bilingual Coordinator at (916) 322-4553.
Submit completed form to:
California Department of Pesticide Regulation
Human Resources Branch, Attention: Bilingual Coordinator
1001 I Street, 4
Floor, MS-4B, Sacramento, CA 95814
th
Fax: (916) 445-6416
Email:
BilingualServices@cdpr.ca.gov
Please answer all questions. You may use additional sheets, if needed.
Complainant Information:
This information is required so that we can contact you to assist with resolving your complaint.
Name:
Primary Language:
Email Address:
Mailing Address:
Telephone Number (daytime):
Alternate Number:
Nature of the problem:
[ ] Not provided interpretation services
[ ] Not provided translated materials
[ ] Interpreters or translators not competent
[ ] Unable to access services, programs or activities
[ ] Services not timely
[ ] Lack of signs informing public of language access services
[ ] Other
− CONTINUED ON REVERSE −
State of California
Department of Pesticide Regulation
LANGUAGE ACCESS ASSISTANCE RESOLUTION FORM
DPR-045 (Rev. 03/18)
Page 2 of 2
Please describe what happened:
Where did this occur? (Physical address or Website)
When did this occur?
If you spoke to someone to request assistance, what was their name?
What is the best time to contact you to discuss your concern?
Day:
Time:
The California Department of Pesticide Regulation is committed to providing services to all members of the
public regardless of English proficiency. Your concern is of the highest priority, and we will make every effort to
contact you within one week of receiving your complaint. If efforts to reach you by telephone and/or email are
unsuccessful, we will send a letter to your home mailing address, as listed.
SIGNATURE
DATE
FOR OFFICE USE ONLY
D ate/Time Received:
__________________
Describe how this complaint was resolved:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Date complainant was notified of resolution:___________ Name of staff who made contact:________________
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