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Title VI Discrimination Complaint

Title VI Discrimination Complaint

Please provide complete information, to enable METRO staff to investigate and respond.
Fields followed by * are required. You may skip a required field that doesn't apply by typing "n/a".
Before filling out any information, please choose the most appropriate Department from the pick-list below.

Your Email *

Your Name *

Department *

Your Phone - Include Area Code *

Preferred method of contacting you *

Your Address

Your City

Your State

Your Zip

Nature of Comment *

Date of Incident *

Time of Incident *

Route *

Choose location *

Location - additional information

Vehicle Number - If Known

Direction of Travel *

Employee Name or Number - If Known

Employee Position *

If Other, Please Describe

Your Phone (include area code): *

Preferred method of contacting you *

Your Address (optional):

Your City (optional):

Your State (optional):

Your Zip (optional):

Nature of Comment:

Date of Incident: *

Time of Incident: *

Did this trip connect with a Fixed-Route Bus?

Location (include street and cross-street):

Vehicle Number (if known):

Employee Name or Number (if known):

Employee Position: *

If other, please describe:

Confidentiality Requested? *

Name of person filing this report:

Which publication does this concern? *

What interests and experience do you have that would make you an effective MAC member? *

Please outline your availability in terms of meeting times/dates and total time per month you can devote to MAC activities: *

Are you aware of any conflicts of interest that would prevent you from serving on MAC if appointed? *

Contact Name *

Street Address *

Street Address

City *

State *

Zip Code *

Day Phone *

Do you ride Santa Cruz METRO fixed route or Paracruz Service *

How often do you use Santa Cruz METRO Fixed Route or METRO ParaCruz Service? *

What are your particular transit interests? *

What do you think are the biggest challenges for Santa Cruz METRO? *

What do you believe that you can contribute to Santa Cruz METRO & MAC if appointed? *

Contact Name *

Company Name *

Address 1 *

Address 2

City *

State *

Zip Code *

Phone Number *

FAX Number

Alternate Email Address

Products/Services Type *

Enter searchable keywords describing your products/services:

Is your firm a Disadvantaged Business Enterprise? (If yes, please answer the following question) *

No Yes

What is your certification number:

Is your firm a Small Business? (If yes, please answer the following question) *

No Yes

Please select the average annual revenue/receipts over the last 3 years:

If you are a DBE, enter your six-digit NAICS code(s): (if you have more than one, separate them with commas)

If you are a Small Business, enter your six-digit NAICS code(s): (if you have more than one, separate them with commas)

First Name *

Last Name *

Organization Name (if any)

Street Address *

Street Address

City *

State *

Zip Code *

Contact Phone *

Specific Description of the Records Requested *

Complainant's Name or Authorized 3rd Party (if different from "Your Name" entered above): *

Please read the Title VI Complaint Procedure before completing this form.

Street Address: *

City: *

State: *

Zip: *

Your Phone (Include Area Code): *

Preferred method of contacting you *

Date and Time of Violation: *

Date of Complaint *

Place of Violation *

Bus Number (if known):

Bus Route:

Please indicate discrimination in this complaint beacuse of any of the following, which are prohibitited by Title VI of the Civil Rights Act of 1964 (check all that apply): *

Race Color National Origin

Please indicate discrimination in this complaint because of any of the following, which are strictly prohibited by Santa Cruz METRO (check all that apply): *

Age Sex Sexual Orientation Gender Identity Disability Other

Other (if applicable)

If known, please provide the name(s) of the METRO Directors, employees and/or agents who allegedly discriminated against you, including their job titles (drag lower-right corner of text area to make larger): *

Identify what METRO service, program or activity resulted in discrimination against you: *

Identify individuals by name, address and phone nuber that have information relating to the violation: *

Explain as clearly as possible what happened, how you feel you were discriminated against and who was involved. Describe how you were treated differently? (For Subject and Message fields below, enter either "N/A" or provide any additional information) *

Your Phone - Include Area Code

Preferred method of contacting you *

This is for Lost & Found only. For all other issues or incidents with METRO Bus Service, please submit a Customer Service Report.

Describe the lost or found item (drag lower-right corner of text area to make larger):

Location where item was lost or found:

If item was lost on a METRO Bus, please provide 4-digit bus number (if known), or use for Other

Date and Time item was Lost or Found:

What route was the bus serving (if applicable)?

This is for Accessible Information requests only. All reports not fitting this purpose will be ignored. Report options are explained on the Customer Service page..

Your Phone - Include Area Code

Preferred method of contacting you *

What is the title of the PDF document or web page you are interested in. Include location on our website if applicable. *

Please read the ADA Complaint Procedure before completing this form.

Do you wish to have your identity kept confidential? *

Yes No

Name of Complainant *

Address of Complainant (include city, state, zip) *

Your Phone - Include Area Code *

Preferred method of contacting you *

Date of Complaint *

Date and Time of Violation *

Place of Violation *

Bus/Van Number (if not applicable, enter"N/A") *

Bus/Van Route (if not applicable, enter"N/A") *

General Description of Driver out of ADA/504 compliance (drag lower-right corner to enlarge): *

Identify service, program or activity out of ADA/504 compliance (drag lower-right corner to enlarge): *

Summary of Violationout of ADA/504 compliance (drag lower-right corner to enlarge): *

Identify individuals by name and address that have information relating to the violation: *

Subject *

Message *

Priority *

Attachment(s)

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Accessible Information Request

ADA 504 Complaint

Customer Service Report

Lost & Found Report

ParaCruz Customer Service Report

Title VI Discrimination Complaint

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