"Language Access Complaint Form" - California

Language Access Complaint Form is a legal document that was released by the California Department of Rehabilitation - a government authority operating within California.

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Department of Rehabilitation
Office of Civil Rights
Phone (916) 558-5850 Fax (916) 558-5851
Language Access Complaint Form and Process
to Submit a Complaint
California State’s policy is to provide services to the public in languages
other than English as required by the Dymally – Alatorre Bilingual Services
Act (Act).
The Department of Rehabilitation (DOR) has several bilingual resources in
place to communicate DOR services to members of the public and to DOR
consumers in languages other than English, as required by the Act. For
example, DOR employs many staff who are certified fluent in a variety of
languages in addition to English; DOR has a telephonic interpretation
service available that provides interpretation into languages other than
English; DOR translates materials regarding the provision of Vocational
Rehabilitation services into six most frequently used languages of DOR
consumers; and DOR can provide American Sign Language Interpreter
resources, as needed.
The DOR will take reasonable steps to resolve Language Access
Complaints submitted to DOR’s Office of Civil Rights.
To submit a
complaint, please complete this form. The information requested in this
form will assist DOR to review and address the complaint. This form can
be submitted by U.S. mail, fax, or email and should be submitted to:
Department of Rehabilitation
Office of Civil Rights
Bilingual Language Coordinator
P.O. Box 944222
Sacramento, California 94244-2220
Fax: (916) 558-5851
Email:
Civil.Rights@dor.ca.gov
Department of Rehabilitation
Office of Civil Rights
Phone (916) 558-5850 Fax (916) 558-5851
Language Access Complaint Form and Process
to Submit a Complaint
California State’s policy is to provide services to the public in languages
other than English as required by the Dymally – Alatorre Bilingual Services
Act (Act).
The Department of Rehabilitation (DOR) has several bilingual resources in
place to communicate DOR services to members of the public and to DOR
consumers in languages other than English, as required by the Act. For
example, DOR employs many staff who are certified fluent in a variety of
languages in addition to English; DOR has a telephonic interpretation
service available that provides interpretation into languages other than
English; DOR translates materials regarding the provision of Vocational
Rehabilitation services into six most frequently used languages of DOR
consumers; and DOR can provide American Sign Language Interpreter
resources, as needed.
The DOR will take reasonable steps to resolve Language Access
Complaints submitted to DOR’s Office of Civil Rights.
To submit a
complaint, please complete this form. The information requested in this
form will assist DOR to review and address the complaint. This form can
be submitted by U.S. mail, fax, or email and should be submitted to:
Department of Rehabilitation
Office of Civil Rights
Bilingual Language Coordinator
P.O. Box 944222
Sacramento, California 94244-2220
Fax: (916) 558-5851
Email:
Civil.Rights@dor.ca.gov
Language Access Complaint Form
Questions regarding Language Access Complaints or the process for submitting a
complaint can be made to DOR’s Office of Civil Rights by calling (916) 558-5850 or via
email at
Civil.Rights@dor.ca.gov
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LTERNATE
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Is someone else filing this complaint for you?
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If Yes, include his/her F
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(please select from the list below)
ATURE OF
OMPLAINT
What was the problem? Check all the boxes in this section that apply
I was denied an interpreter in the following language:
____________________
The interpreter(s) skills were not good (List the name of the
Interpreter, if known, and Non English language needed)
_____________________________________________
I was not given translated materials in the Non English language I
can understand (List language and document(s) needed, if known)
_________________________________________________
I was unable to use services, programs or activities due to a
language barrier
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Language Access Complaint Form
Other (Explain below)
Below, please provide specific date, DOR Office location, name of
DOR staff, if known, and describe briefly what happened.
Date problem occurred: Month: ____________ Day: _____ Year: ______
DOR Office where problem occurred: _____________________________
Name of DOR Staff involved, if applicable: __________________________
Briefly describe what happened:
How did you and/or DOR 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
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