Form DBO-EEO139 "Language Access Complaint Form" - California

What Is Form DBO-EEO139?

This is a legal form that was released by the California Department of Financial Protection and Innovation - 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 1, 2018;
  • The latest edition provided by the California Department of Financial Protection and Innovation;
  • 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 DBO-EEO139 by clicking the link below or browse more documents and templates provided by the California Department of Financial Protection and Innovation.

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Download Form DBO-EEO139 "Language Access Complaint Form" - California

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STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
LANGUAGE ACCESS COMPLAINT FORM
DBO-EEO 139 (Rev. 10-18)
Instructions for completing this form and routing it to the person handling this complaint is listed
below:
The Department of Business Oversight’s (DBO) policy is to take reasonable steps to overcome language
barriers to public services and programs. To do this, our goal is to:
Talk to you in your language, and
1.
Make vital forms and documents accessible in your language.
2.
Your comments on this form will help us towards that goal. All information is confidential. Please print,
and sign the form. Then send it by mail or email as shown below:
Department of Business Oversight
Equal Employment Opportunity Office
1515 K Street, Suite 200
Sacramento, CA 95814
PART A: PERSON MAKING THE COMPLAINT
FIRST NAME:
LAST NAME:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
TELEPHONE NUMBER:
E-MAIL ADDRESS:
PREFERRED LANGUAGE:
IS SOMEONE ELSE HELPING YOU FILE
IF YES, PROVIDE THEIR NAME BELOW:
THIS COMPLAINT?
FIRST NAME:
LAST NAME:
YES
NO
PART B: NATURE OF THE PROBLEM
Check all boxes that apply and explain below:
I was not offered an interpreter.
I asked for an interpreter and was denied.
The interpreter(s) or translator(s) skills were not competent.
The interpreter(s) made rude or inappropriate comments.
The services took too long (Explain below).
I was not given forms or notices in a language I can understand (List documents needed below).
I was unable to use services, programs, or activities (Explain below).
Other (Explain below).
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERSIGHT
LANGUAGE ACCESS COMPLAINT FORM
DBO-EEO 139 (Rev. 10-18)
Instructions for completing this form and routing it to the person handling this complaint is listed
below:
The Department of Business Oversight’s (DBO) policy is to take reasonable steps to overcome language
barriers to public services and programs. To do this, our goal is to:
Talk to you in your language, and
1.
Make vital forms and documents accessible in your language.
2.
Your comments on this form will help us towards that goal. All information is confidential. Please print,
and sign the form. Then send it by mail or email as shown below:
Department of Business Oversight
Equal Employment Opportunity Office
1515 K Street, Suite 200
Sacramento, CA 95814
PART A: PERSON MAKING THE COMPLAINT
FIRST NAME:
LAST NAME:
STREET ADDRESS:
CITY:
STATE:
ZIP CODE:
TELEPHONE NUMBER:
E-MAIL ADDRESS:
PREFERRED LANGUAGE:
IS SOMEONE ELSE HELPING YOU FILE
IF YES, PROVIDE THEIR NAME BELOW:
THIS COMPLAINT?
FIRST NAME:
LAST NAME:
YES
NO
PART B: NATURE OF THE PROBLEM
Check all boxes that apply and explain below:
I was not offered an interpreter.
I asked for an interpreter and was denied.
The interpreter(s) or translator(s) skills were not competent.
The interpreter(s) made rude or inappropriate comments.
The services took too long (Explain below).
I was not given forms or notices in a language I can understand (List documents needed below).
I was unable to use services, programs, or activities (Explain below).
Other (Explain below).
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERISGHT
LANGUAGE ACCESS COMPLAINT FORM
DBO-EEO 139 (Rev. 10-18) Page 2 of 3
When did the problem happen?
Date: (MM/DD/YYYY)
__________________________
Time:
AM
PM
___________________
Where did the problem happen?
Describe what happened:
Did you complain to anyone from the Department/Agency? Who and what was the response?
Please be specific.
PART C: RESOLUTION
Date: (MM/DD/YY)
___________________________
Resolution:
(I certify that this statement is true to the best of my knowledge and belief)
_____________________________
_______________
Signature:
Date: (MM/DD/YYYY):
STATE OF CALIFORNIA – DEPARTMENT OF BUSINESS OVERISGHT
LANGUAGE ACCESS COMPLAINT FORM
DBO-EEO 139 (Rev. 10-18) Page 3 of 3
DBO’s Privacy Notice on Collection
DBO Collects and Uses Personal Information: The DBO collects the information requested on
this form pursuant to the Dymally-Alatorre Bilingual Services Act authorizing DBO to collect
personal information. The DBO uses this information for the purposes of providing better services
to the limited and non-English speaking public. Use of the personal Information DBO collects is
subject to limitations contained in the Information Practices Act of 1977 and other applicable state
and federal laws.
Providing Personal Information Is Voluntary: If you do not want to provide personal
information, such as your name, home address or home telephone number, you may remain
anonymous. However, we may not be able to contact you or help resolve your issue.
When providing information or documents, please do not include unrequested personal
information such as a Social Security number, driver’s license number, or financial information.
DBO May Disclose Your Personal Information: We may share your personal information with
the California Department of Human Resources (CalHR), the Department of Fair Employment and
Housing, the Equal Employment Opportunity Commission, and other state and federal
government departments as required by law. Your personal information may also be disclosed:
• In response to a Public Records Act request, as allowed by the Information Practices Act.
• To another governmental agency as required by state or federal law.
• In response to a court order or administrative order, a subpoena or a search warrant.
Your Access to Your Personal Information: You may review the records maintained by DBO
that contain your personal information. To request access, contact: DBO Privacy Officer, 1515 K
Street, Sacramento, CA 95814, (866) 275-2677.
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