Title VI Complaint Procedures FORM

WestFair Rides, Inc., dba TRA

 

YOU CAN DOWNLOAD A COPY OF THIS FORM BY CLICKING HERE.

 

Title VI Complaint Procedures 

49 CFR  21.1, provides that, “No person in the United States shall, on the grounds of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity receiving Federal financial assistance from the Department of Transportation.” 

 

Who may file a Title VI complaint? 

A complaint may be filed by any person who believes they or any specific class of persons has been subjected to discrimination.

In order to comply with Title VI and all of the regulations of 49 CFR Part 21, TRA, provides the following complaint procedures for those persons who believe that they have been subjected to discrimination under any program or activity receiving Federal financial assistance from the United States Department of Transportation. These procedures do not deny the right of the complainant to file a formal complaint with other State or Federal agencies or to seek private counsel for complaints alleging discrimination.

 

How and where is a discrimination complaint filed? 

A complaint must be in writing, signed by the person(s) or their representative(s) and must include the complainant(s) name, address and telephone number. Below is a Discrimination Complaint Form that may be used, however, a complaint may also be filed by sending the complaint by facsimile or electronic mail. 

 

How long will it take for my complaint to be resolved? 

The complaint will be reviewed by Catherine Wynkoop, President of TRA. Where practicable, the complainant shall be notified, in writing, of the findings and remedial action, if any, within a period not to exceed 60 days. 

 

A signed written complaint must be filed within 180 days of the date of the alleged discrimination. The signed complaint must be sent to:

 

Contact Person for Title VI/Discrimination Complaints:  Catherine Wynkoop, President     

Agency:  TRA 

Address:  487 East Main Street #218, Mount Kisco, NY 10549 

 

 

NYS Department of Transportation Discrimination Complaint Form 

General Instructions for Completing the Complaint Application

Unless otherwise indicated, applicants are required to complete all required fields as they appear in the application. 

 

PART A: Complainant Contact Information

 

Complainant Contact Information:     

First Name:                                          Last Name:

Title:

Address 1:

Address 2:

City:                      State:            Zip Code:                 

Phone #: (       )                                                                                                                 

E-mail:

 

 

PART B: Complaint

 

Name of the Entity/individual against which this complaint is being filed:

Location of incident:

Address 1:

Address 2:

City:                      State:            Zip Code:

Phone #: (        )    

 

PART C: Complaint Details

 

Please place an ‘X’ on the appropriate line(s). Select the phrase that best represents what occurred.

 

–  DISCRIMINATION

        i.         I received negative comments, racial slurs, or other unwelcome remarks, or questions because of my: (Place an ‘X’ next to all that apply)   

 

Age
Gender
National Origin
Race
Religion
Other

    

 

       

 

PART C: Complaint Details-continued

 

ii.         I was denied equal access to: (place an ‘X’ next to all that apply)

 

Contracting Opportunities
Information
Programs
Public Transportation
Services
Training
Other

  because of my: (place an ‘X’ next to all that apply)

 

Age
Disability
Gender
Limited English Lang. Proficiency
National Origin
Race
Religion
Other

 

 

In the space below, provide any other details regarding your complaint that you would like considered that have not already been addressed in this form.

 

 

 

–    HARASSMENT

 

i.     I was: (place an ‘X’ next to all that apply)

 

Harassed
Subjected to unfair worksite policies and practices
Subjected to unfair bidding practices
Other

PART C: Complaint Details-continued

 

ii.    I was sexually harassed because I: (place an ‘X’ next to all that apply)

 

Was subjected to unwelcome sexual advances and/or sexually charged comments
Am/was exposed to sexually explicit pictures/posters posted in common and/or public areas
Other

 

In the space below, provide any other details regarding your complaint that you would like considered that have not already been addressed in this form.

 

 

–  LANGUAGE ACCESS

 

Regarding barriers to equal access, select all that apply to your experience: (place an ‘X’ next to all that apply)

 

Written information related to instructions, directions, or vital information was not available in my native language.
Translation services I requested were not made available to me for live or recorded events, presentations, or trainings.
I was denied an accommodation to enter a building, or to access a facility or room in the building.
There were no signs conspicuously posted notifying me of wheelchair accessibility.
Readers and/or interpreters for the blind and/or hearing impaired I requested were not provided to me.

 

 

 

In the space below, provide any other details regarding your complaint that you would like considered that have not already been addressed in this form.

 

 

PART C: Complaint Details- continued

 

– ADA

 

 I could not access public transportation, a public facility, or public right of way because: (place an ‘X’ next to all that apply)

 

Of physical barriers e.g. Improper ramps, lack of equipment or crossing aids, etc.)
The bus did not have chair lifts or there was no bus-lowering mechanism.
The sidewalks, roadways or public facility was not maintained to allow access.
The paratransit bus schedule does not accommodate my activities of daily living.
The bus routes do not sufficiently deviate from routes to accommodate me.
The vehicles, shelters. and/or other facilities are not accessible to me.

 

 

In the space below, provide any other details regarding your complaint that you would like considered that have not already been addressed in this form.

 

 

–  FRAUD 

      i.         I witnessed a disadvantaged business enterprise (DBE), a minority or women owned (M/WBE), or a service disabled veteran owned (SDVOB) firm not performing the contractual commercially useful function (CUF) on a NYSDOT contract. 

The firm is:

Contractual services that were to be performed include:                                                      

                                   

___      Place an ‘X’ on the line to attach any documents or photos that substantiate your complaint.

PART C: Complaint Details- continued

 

     ii.         I have not been paid promptly for the work I have performed as follows: (place an ‘X’ next to one) 

 

I have not received any payments
I have received some and/or partial payments
I received full payments, but they are late
I received partial payments and they are late

  

 

   iii.         My payment is   _________ days late. Attach the following documentation to this complaint: 

 

Place an ‘X’ in the next box to attach the signed contract/agreement between your firm and the Prime Contractor that outlines the scope of services and payment or reimbursement schedules for services or supplies.
Place an ‘X’ in the next box to attach documentation to support that your firm fulfilled its obligations in the project, e.g. signed delivery slips, payroll reports, etc.
Place an ‘X’ in the next box to attach documentation or communications from the Prime Contractor regarding any payment issues or reasons why you have not been compensated.
If you received partial payments, place an ‘X’ in the next box to attach a listing of the payment dates and amounts received.

 

 

   iv.         My firm was negatively affected by a removal or substitution for an approved item of work for project:    _____________       Location:

(Project No.)                                                                                                                                                                                                                                                                                                                                                                                                                           

Attach the following documentation to this complaint:

 

Place an ‘X’ in the next box to attach documentation to support the original scope of the project.
Place an ‘X’ in the next box to attach documentation or communications from the Prime Contractor regarding why your firm’s scope of work was being removed from the project or why your firm was being replaced with another firm.

 

PART C: Complaint Details- continued

 

     v.         A Prime Contractor did not negotiate a bid with me/my firm in good faith.

 

Place an ‘X’ in the next box to attach any documents or other information that substantiates your complaint.

 

In the space below, provide any other details regarding your complaint that you would like considered that have not already been addressed in this form. 

 

 

PART D: Additional Information 

 

      i.         Were there any witnesses to the action or inaction leading to your complaint? (Place an ‘X’ in the box next to your response)

 

Yes
No
Unknown

 

Please provide the name(s) and contact information for any witness  

 

 

PART D: Additional Information 

 

     ii.         Was this complaint filed with another agency?  (Place an ‘X’ in the box next to your response)

Yes
No

 

Filed with: (Place an ‘X’ in the box next to your response)

 

Local Entity
Private Entity
Human Rights Commission
Department of Justice
USDOT-FTA

 

          

   iii.         Were you the recipient of intimidation or retaliatory actions because you filed a complaint?

(Place an ‘X’ in the box next to your response)

 

Yes
No

 

      

PART E: Complaint Submission

 

 

 

Signature:                                                                                                          Date:

 

 

 

Completed forms may be submitted to: CivilRights@dot.ny.gov 

 

or

Department of Transportation

Office of Civil Rights

50 Wolf Road

Albany, NY 12232