Title VI Program & Complaint Form

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Title VI Program & Complaint Form

Download the City of Elk Grove's Title VI and Limited English Proficiency Plan

The City of Elk Grove is committed to ensuring that no person is excluded from participation in or denied the benefits of its services on the basis of race, color or national origin, as provided by Title VI of the Civil Rights Act of 1964, as amended. Title VI complaints must be filed within 180 days of the alleged discrimination.

The following information is necessary to assist us in processing your complaint. If you require any assistance in completing this form, please contact the Title VI Coordinator.

The completed form must be returned to:

Title VI Coordinator
Mike Costa
8401 Laguna Palms Way
Elk Grove, CA 95758
Phone: (916) 687-3030
Email: mcosta@elkgrovecity.org

Procedures for Investigating Complaints
The Transit System Manager will investigate the complaint and make a determination. Formal investigation of the complaint will be confidential and will include, but is not limited to, details of the specific incident, frequency and dates of occurrences, and names of any witnesses.  The complainant will be notified of the resolution.

Appeals Process
If the complainant is not satisfied with the resolution, an appeal process is available.  An appeal request for review of a determination of unlawful denial of access or accommodation to public transportation must be filed, in writing, within sixty (60) calendar days of the incident.  The written appeal must include the customer’s name, address, and telephone number. A statement of reason(s) why the complainant believes the denial of the complaint was inappropriate is recommended.

The City Manager will set a mutually agreed-upon time and place for the review process with the complainant and/or his/her representatives within thirty (30) days of the request.  The complainant may submit documents or other information to be included with the record and considered in the review process.  A record of the review will be kept, as determined by the City Manager.  Anyone needing special accommodations may contact the City at (916) 683-7111 for assistance.

Title VI Complaint Form

Title VI Complaint Form
Your Name:
Street Address:
City/State/Zip::
Phone:
Alt Phone:
Person(s) discriminated against (if someone other than complainant):
Person Name(s):
Person's Street Address :
Person's City/State/Zip :
Which of the following best describes the reason the alleged discrimination took place?
If other selected for reason for discrimination please provide details:
Date of Incident:
Please describe the alleged discrimination incident. Provide the names and titles of all City of Elk Grove (or it’s Contractor MV Transportation, Inc.) employees involved, if available. Explain what happened and whom you believe was responsible:

Have you filed a complaint with any other federal, state or local agencies regarding this incident?
If so, list agency/agencies and contact information below:
Agency 1:
Contact Name 1:
Street Address 1:
City/State/Zip 1:
Phone 1:

Agency 2:
Contact Name 2:
Street Address 2:
City/State/Zip 2:
Phone 2:
The City will make every effort to address your concern within a reasonable period of time. You will be contacted by the Title VI Coordinator within ten (10) business days. If your concern pertains to an agency other than the City of Elk Grove, we will forward this form to the responsible agency.
All written complaints and responses will be retained by the City of Elk Grove for at least three years.
If the response by the Title VI Coordinator or designee does not satisfactorily resolve the concern, the complainant may appeal the decision within sixty (60) calendar days after receipt of the response to the City Manager or designee.
By clicking on "Submit" below, I affirm that I have read the above charge and that it is true to the best of my knowledge, information, and belief.

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