"Language Access Complaint Form - Draft" - California

Language Access Complaint Form - Draft is a legal document that was released by the California Department of Forestry & Fire Protection - a government authority operating within California.

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Department of Forestry and Fire Protection
Equal Employment Opportunity Office
P.O. Box 944246
Sacramento, California 94244-2460
Phone (916) 653-0422 Fax (916) 654-9988
Language Access Complaint Form
If you feel we have been unable to serve you because of language barriers or non-compliance with the
Dymally-Alatorre Bilingual Services Act, CAL FIRE may be able to provide additional assistance in serving
your requested needs. Please provide the following information and we will attempt to resolve your
concern(s) in a timely manner.
Y
F
N
Y
L
N
OUR
IRST
AME
OUR
AST
AME
H
P
O
P
OME
HONE
THER
HONE
S
A
C
TREET
DDRESS
ITY
S
Z
TATE
IP
Y
N
Is someone else filing this complaint for you?
ES
O
If Yes, include his/her F
N
L
N
IRST
AME
AST
AME
N
C
(please select one)
ATURE OF
OMPLAINT
Lack of assistance by CAL FIRE staff in your
Lack of translated materials in your language.
language.
Interpreter available was not skilled/knowledgeable.
Translations were not accurate.
Other: Explain
Describe briefly what happened. Please provide specific names and addresses where possible.
(Attach additional pages as needed.)
How did you and CAL FIRE attempt to resolve the problem? Please be specific as possible.
I certify that this statement of my complaint above and on any pages attached is true to the best of my
knowledge and belief.
S
D
(MM/DD/YYYY)
IGNATURE
ATE
You may file a complaint against our department for lack of adequate access to your language with the CA
Department of Human Resources, 1515 S Street, Sacramento, CA 95814.
Department of Forestry and Fire Protection
Equal Employment Opportunity Office
P.O. Box 944246
Sacramento, California 94244-2460
Phone (916) 653-0422 Fax (916) 654-9988
Language Access Complaint Form
If you feel we have been unable to serve you because of language barriers or non-compliance with the
Dymally-Alatorre Bilingual Services Act, CAL FIRE may be able to provide additional assistance in serving
your requested needs. Please provide the following information and we will attempt to resolve your
concern(s) in a timely manner.
Y
F
N
Y
L
N
OUR
IRST
AME
OUR
AST
AME
H
P
O
P
OME
HONE
THER
HONE
S
A
C
TREET
DDRESS
ITY
S
Z
TATE
IP
Y
N
Is someone else filing this complaint for you?
ES
O
If Yes, include his/her F
N
L
N
IRST
AME
AST
AME
N
C
(please select one)
ATURE OF
OMPLAINT
Lack of assistance by CAL FIRE staff in your
Lack of translated materials in your language.
language.
Interpreter available was not skilled/knowledgeable.
Translations were not accurate.
Other: Explain
Describe briefly what happened. Please provide specific names and addresses where possible.
(Attach additional pages as needed.)
How did you and CAL FIRE attempt to resolve the problem? Please be specific as possible.
I certify that this statement of my complaint above and on any pages attached is true to the best of my
knowledge and belief.
S
D
(MM/DD/YYYY)
IGNATURE
ATE
You may file a complaint against our department for lack of adequate access to your language with the CA
Department of Human Resources, 1515 S Street, Sacramento, CA 95814.