Florida Department of Transportation Title VI Complaint Procedure
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1 FTA Circular B, Chapter III, Paragraph 6: All recipients shall develop procedures for investigating and tracking Title VI complaints filed aginst them and make their procedures for filing a complaint available to member of the public. Any person who believes he or she has been discriminated against on the basis of race, color, or national origin by The Arc of Palm Beach County may file a Title VI complaint by completing and submitting the agency s Title VI Complaint Form. Complaints can also be submitted by calling the title VI Liaison at (561) The Arc of Palm Beach County investigates complaints received no more than 180 days after the alleged incident. The Arc of Palm Beach County will only process complaints that are complete. To be considered complete, complainants must, at a minimum, include their name, contact information, date of alleged incident, and a description of the incident. Once the complaint is received, The Arc of Palm Beach County will review it to determine if our office has jurisdiction. The complainant will receive an acknowledgement letter informing him/her whether the complaint will be investigated by our office. The Arc of Palm Beach County has ninety (90) days to investigate the complaint. If more information is needed to resolve the case, The Arc of Palm Beach County may contact the complainant. The complainant has ten (10) business days from the date of the letter to send requested information to the investigator assigned to the case. If the investigator is not contacted by the complainant or does not receive the additional information within ten (10) business days, The Arc of Palm Beach County can administratively close the case. A case can also be administratively closed if the complainant no longer wishes to pursue their case. After the investigator reviews the complaint, she/he will issue one of two letters to the complainant: a closure letter or a letter of finding (LOF). A closure letter summarizes the allegations and states that there was not a Title VI violation and that the case will be closed. A LOF summarizes the allegations and the interviews regarding the alleged incident, and explains whether any disciplinary action, additional training of the staff member or other action will occur. If the complainant wishes to appeal the decision, she/he has seven (7) days to do so from the time he/she receives the closure letter or the LOF. The complaint procedures and forms will be made available to the public at The Arc of Palm Beach County. The forms are also available in other formats upon request.
2 Section I: Name: Address: Florida Department of Transportation Title VI Complaint Procedure Complaint Form Telephone (Home): Electronic Mail Address: Accessible Format Requirements? Section II: Large Print TDD Telephone (Work): Audio Tape Other Are you filing this complaint on your own behalf? Yes* *If you answered "yes" to this question, go to Section III. If not, please supply the name and relationship of the person for whom you are complaining: Please explain why you have filed for a third party: Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party. Section III: I believe the discrimination I experienced was based on (check all that apply): Yes [ ] Race [ ] Color [ ] National Origin [ ] Age [ ] Disability [ ] Family or Religious Status [ ] Other (explain) Date of Alleged Discrimination (Month, Day, Year): Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include the name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses. If more space is needed, please use the back of this form. Section IV Have you previously filed a Title VI complaint with this agency? Yes
3 Section V Have you filed this complaint with any other Federal, State, or local agency, or with any Federal or State court? [ ] Yes [ ] If yes, check all that apply: [ ] Federal Agency: [ ] Federal Court [ ] State Agency [ ] State Court [ ] Local Agency Please provide information about a contact person at the agency/court where the complaint was filed. Name: Title: Agency: Address: Telephone: Section VI Name of agency complaint is against: Contact person: Title: Telephone number: You may attach any written materials or other information that you think is relevant to your complaint. Signature and date required below Signature Date Please submit this form in person at the address below, or mail this form to: The Arc of Palm Beach County Title VI Liaison Kristie Pirozzi Compliance Officer Australian Ave. Riviera Beach, FL kpirozzi@arcpbc.org
4 FORMA DE QUEJA Seccion I: Escribir en forma legible 1. mbre: 2. Direccion: 3. Telefono: 3.a. Telefono secundario(opcional): 4. Direccion de correo electronico: 5.Reuistos de forma accesible? Secccion II: Impresion grande TDD Cinta de audio Otros 6.Esta presentando esta queja en su propio nombre? Si * *Si usted contesto Si a #6, vaya a la Seccion III. 7. Si usted contest a #6 cual es el nombre de la persona a la que usted presentanto esta que ja? mbre: 8. Cual es su relacion con este individuo: 9. Por favor, explique por que han presentado para una tercera parte: 10. Por favor, confirme que ha obtenido el permiso de la parte agraviada en el archivo en su nombre. Seccion III: Si 11.Creo que la discriminacion que he experimentado fue basado en (marqu todas las que correspondan): [ ] Raza [ ] Color [ ] Origin nacional [ ] Edad [ ] Discapacidad [ ] Familia o Estatus Religioso [ ] Othros 12. Fecha de supuesta discriminacion: (mm/dd/aaaa) 13.Explica lo mas claramente posible lo que ocurrio y por que usted cree que son objeto discriminacion. Describir todas las personas que han participado. Incluir el nombre y la informacion de contacto de la(s) persona(s) que discrimina contra usted (si se conoce), asi como los nombres y la informacion de contacto de los testigos. Si se necesita mas espacio, por favor adjunte hojas adicionales de papel Section IV 14. Anteriormente ha presentado un Titulo VI denuncia con the City of Inglewood. Si
5 Seccion V 15. Ha presentado esta queja con cualquier otro local, estato o federal, o con cualquier Federal o Estato? [ ] Si * [ ] si la respuesta es si Marque todo lo que apliqua: [ ] Agencia Federal: [ ] Federal Tribunal [ ] Agencia Estatal [ ] Tribunal Estatal [ ] Agencia Local 16. Si usted contesto "si" a la posicion #15, proporcionan informacion acerca de una persona de contacto en la agencia/tribunal donde se presento la denuncia. mbre: Titulo: Organismo:: Direccion: Telefono: Section VI Correo electronico: mbre de organismo Transito denuncia es contra: Persona de contacto: Telefono: Usted puede adjuntar cualquier material escrito u otra información que considere relevante para su reclamación. Firma y fecha son necesarios para completer la forma siguiente: Firma: Fecha: Por favor, envíe este formulario en persona o por correo este formulario a la siguiente dirección: The Arc of Palm Beach County Title VI Liaison Kristie Pirozzi Compliance Officer Australian Ave. Riviera Beach, FL kpirozzi@arcpbc.org
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