"Language Access Complaint Form" - California

Language Access Complaint Form is a legal document that was released by the California Public Employees' Retirement System - a government authority operating within California.

Form Details:

  • Released on December 1, 2018;
  • The latest edition currently provided by the California Public Employees' Retirement System;
  • 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 fillable version of the form by clicking the link below or browse more documents and templates provided by the California Public Employees' Retirement System.

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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, CalPERS 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.
Your First Name:
Your Last Name:
Phone Number:
Other Phone:
Street Address:
City:
State:
Zip:
Is someone else filing this complaint for you?
Yes
No
If “Yes,” include their first name:
Last Name:
Nature of Complaint (please select one):
Lack of assistance by CalPERS staff in your language
Lack of translated materials in your language
Interpreter available was not skilled/knowledgeable
Translations were not accurate
Other:
Describe briefly what happened. Please provide specific names and addresses where possible.
Attach additional pages as needed.
How did you and CalPERS 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.
Signature:
Date (MM/DD/YYYY):
You can submit this form and any supporting documentation by:
Email to EEO@calpers.ca.gov
Mail to CalPERS EEO Program - Attention: Equal Employment Opportunity Office
400 Q Street Room 3340, Sacramento, CA 95811
Fax to (916) 795-3659
Revised 12/2018
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, CalPERS 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.
Your First Name:
Your Last Name:
Phone Number:
Other Phone:
Street Address:
City:
State:
Zip:
Is someone else filing this complaint for you?
Yes
No
If “Yes,” include their first name:
Last Name:
Nature of Complaint (please select one):
Lack of assistance by CalPERS staff in your language
Lack of translated materials in your language
Interpreter available was not skilled/knowledgeable
Translations were not accurate
Other:
Describe briefly what happened. Please provide specific names and addresses where possible.
Attach additional pages as needed.
How did you and CalPERS 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.
Signature:
Date (MM/DD/YYYY):
You can submit this form and any supporting documentation by:
Email to EEO@calpers.ca.gov
Mail to CalPERS EEO Program - Attention: Equal Employment Opportunity Office
400 Q Street Room 3340, Sacramento, CA 95811
Fax to (916) 795-3659
Revised 12/2018