Civil Rights Complaint Form

CIVIL RIGHTS ACT COMPLAINT FORM

Los Angeles County Public Works (Public Works) is committed to ensuring compliance with Title VI of the Civil Rights Act of 1964 and other nondiscrimination authorities, that no person shall be excluded from participation in or be denied the benefits of, or be subjected to discrimination under any program or activity sponsored or implemented by Public Works on the grounds of race, color, national origin, sex, age, disability, religion, sexual orientation, gender identity, or any other category protected by State or Federal law. If you believe you have been discriminated against, please complete this form.

Person Completing Form (select one):

Complaintant Authorized Representative *

* An authorized representative is a person with authority to act in the best interest of the participant.

Occurrence Date

May 2023
	S	M	T	W	T	F	S
18	30	1	2	3	4	5	6
19	7	8	9	10	11	12	13
20	14	15	16	17	18	19	20
21	21	22	23	24	25	26	27
22	28	29	30	31	1	2	3
23	4	5	6	7	8	9	10

Customer Information:

First Name

Last Name

Authorized Representative (if applicable):

First Name

Last Name

Address

City

State

Zip Code

Telephone Number

E-mail Address

Accessibility Complaint Information:

I believe the discrimination I experienced was based on (check all that apply):

Race
Religion
Gender
Color
Age
National Origin
Disability
Other

Please provide additional information if selected "other".

Name of Public Works program or location where service was received, which is the subject of this complaint:

Please describe how Public Works has not complied with delivering its programs and services. Provide sufficient details to support your complaint.

	S	M	T	W	T	F	S
18	30	1	2	3	4	5	6
19	7	8	9	10	11	12	13
20	14	15	16	17	18	19	20
21	21	22	23	24	25	26	27
22	28	29	30	31	1	2	3
23	4	5	6	7	8	9	10

	S	M	T	W	T	F	S
18	30	1	2	3	4	5	6
19	7	8	9	10	11	12	13
20	14	15	16	17	18	19	20
21	21	22	23	24	25	26	27
22	28	29	30	31	1	2	3
23	4	5	6	7	8	9	10

	S	M	T	W	T	F	S
18	30	1	2	3	4	5	6
19	7	8	9	10	11	12	13
20	14	15	16	17	18	19	20
21	21	22	23	24	25	26	27
22	28	29	30	31	1	2	3
23	4	5	6	7	8	9	10