Compliance Concern

2. Name*

3. Gender

   1. Male
   2. Female

5. Address*

7. City*

8. State*

9. Zip Code*

11. Phone Number*

12. Alternate Number

13. Email Address

15. Category of Discrimination

    1. Race
    2. Religion
    3. Color
    4. Disability

    1. National Origin
    2. Sex
    3. Age

16. Identify Race of the Complaint

    1. Black
    2. American Indian
    3. White
    4. Alaskan Native

    1. Hispanic
    2. Pacific Islander
    3. Asian American
    4. Other

18. Date and Place of alleged discriminatory action(s)

20. Names of individuals responsible for the discriminatory action(s)

22. How were you discriminated against?

    Describe the nature of the action, decision, or conditions of the alleged discrimination. Explain as clearly as possible what happened and why you believe your protect status was a factor.

24. Retaliation

    If you feel that you have been retaliated against, separate from the discrimination alleged above, please explain the circumstances.

26. Additional Person(s)

    Provide the name and contact information for any person(s) whom we may contact for additional information

28. Have you filed, or intend to file, a complain with the following?

    1. No/Not at this Time
    2. NC Department of Transportation
    3. Federal Transit Administration

    1. Federal Highway Administration
    2. US Department of Transportation

    1. Federal or State Court
    2. Other

30. Remedy and/or Action

    Briefly explain what remedy or action you are seeking for the alleged discrimination

Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit

* indicates a required field