"Language Access Complaint Form" - California

Language Access Complaint Form is a legal document that was released by the California State Controller’s Office - a government authority operating within California.

Form Details:

  • Released on May 1, 2021;
  • The latest edition currently provided by the California State Controller’s Office;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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

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LANGUAGE ACCESS COMPLAINT FORM
Please use this form to report any language access complaint you have encountered at the State Controller’s
Office. Please return this form and any supporting documentation by mail to the State Controller’s EEO/Disability
Office at 300 Capitol Mall, Suite 275, Sacramento, CA 95814 or send an email with the attached complaint form to
Phillina Lyles, EEO/Disability Manager at plyles@sco.ca.gov. If you have any questions or concerns you may
contact the EEO Office at (916) 324-2223.
1. COMPLAINANT’S CONTACT INFORMATION
Name:
Address:
Phone Number:
Email:
2. COMPLAINT DETAILS
Date of Incident:
Department/Division:
Location or Address:
What language did you
need assistance with?
Chinese
Indian
Japanese
Russian
Spanish
check one that applies)
(
Tagalog
Vietnamese
Urdu
Other: ____________________
Brief Description of Complaint (attach additional pages if needed):
3. FORM ASSISTANCE
Did someone assist you in completing this form?
Yes (input information below)
No (leave blank)
Name:
Organization:
Phone Number:
4. COMPLAINTANT’S SIGNATURE
LANGUAGE ACCESS COMPLAINT FORM
Please use this form to report any language access complaint you have encountered at the State Controller’s
Office. Please return this form and any supporting documentation by mail to the State Controller’s EEO/Disability
Office at 300 Capitol Mall, Suite 275, Sacramento, CA 95814 or send an email with the attached complaint form to
Phillina Lyles, EEO/Disability Manager at plyles@sco.ca.gov. If you have any questions or concerns you may
contact the EEO Office at (916) 324-2223.
1. COMPLAINANT’S CONTACT INFORMATION
Name:
Address:
Phone Number:
Email:
2. COMPLAINT DETAILS
Date of Incident:
Department/Division:
Location or Address:
What language did you
need assistance with?
Chinese
Indian
Japanese
Russian
Spanish
check one that applies)
(
Tagalog
Vietnamese
Urdu
Other: ____________________
Brief Description of Complaint (attach additional pages if needed):
3. FORM ASSISTANCE
Did someone assist you in completing this form?
Yes (input information below)
No (leave blank)
Name:
Organization:
Phone Number:
4. COMPLAINTANT’S SIGNATURE
I certify that this statement of my complaint above and any pages attached is true to the best of my
knowledge and belief.
Signature: _________________________________________
Date: _________________________________
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
DEPARTMENTAL USE ONLY:
Date Received:
Action Taken:
Contact Person:
Phone:
Email:
The State Controller’s Office
May 2021
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