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Run: Title VI Complaint Procedure and Investigation Log

Track Title VI discrimination complaints from intake through investigation, timeliness review, findings, and closure in one log. Use it to document the 180-d...

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Submission Notice

Submission type (required)

Submitter identity (required)

Consent to process personal information (required)

By submitting this form, you consent to the organization using the personal information provided only for complaint intake, review, investigation, resolution, recordkeeping, and required reporting. Do not include SSNs, full financial account numbers, or other unnecessary PII.

Yes No N/A

Request anonymous submission where permitted

Select this if you want to limit identifying information. Anonymous submissions may reduce the organization’s ability to investigate or follow up.

Yes No N/A

Complaint Intake

Complainant name

Optional if anonymous submission is requested or not permitted to collect. Provide only if needed for follow-up.

Preferred contact email

Use only if you want updates by email.

Preferred contact phone

Use only if you want updates by phone.

Preferred language

Optional. Helps support accessible communication and language assistance.

Date of alleged discriminatory incident (required)

Enter the date the alleged discrimination occurred.

Date complaint was received (required)

This is the date the organization received the complaint.

Basis of complaint (required)

Select all that apply.

Program, service, or activity involved (required)

Identify the federally funded program, service, or activity involved.

Location of incident

Provide the location if known.

Complaint summary (required)

Describe what happened, who was involved, and what outcome is being requested. Avoid unnecessary personal details.

Supporting documents

Upload any relevant documents, screenshots, or correspondence.

180-Day Filing Window Review

Days since alleged incident

Calculated from the alleged incident date and the date received.

Filed within 180 days (required)

Title VI complaints are generally expected to be filed within 180 days of the alleged discriminatory act.

Timeliness rationale

Document the reason for acceptance, dismissal, or exception review when the complaint is outside the 180-day window.

Intake decision (required)

Investigation Tracking

Case number

Automatically assigned complaint identifier.

Assigned investigator

Name or role of the assigned investigator.

Assignment date

Investigation status (required)

Status update notes

Record progress updates, outreach attempts, and any barriers to completion.

Interviews conducted

Enter the number of interviews completed.

Evidence reviewed

Findings and Resolution

Finding

Corrective action required

Yes No N/A

Corrective action description

Resolution date

Complainant notified

Closure notes

Summarize final disposition, notifications, and any follow-up actions.

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Email (required)

Your name (optional)

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