WIOA Title I Complaint Form

Items marked with an asterisk(*) are required.

Complainant Contact Information

Name* (First, Middle Initial, and Last)

Home Phone*

Business Phone

Address*

State Agency you believe has discriminated or retaliated

Agency*

Department (if known)

Agency Location

Complaint Information

Is the complaint in connection to your participation in a WIOA program?

Have you contacted the agency regarding this complaint?

Yes

If yes, date of contact

Who did you speak with?

Basis for complaint

Date of Incident*

Where did the incident occur?

Describe the details of the incident:*

What is the desired outcome of this complaint:

Witness Information

If applicable.

Name (First, Middle Initial, and Last)

Home Phone

Business Phone

Address

May we contact this witness?

Yes

Electronic Signature

I CERTIFY the information furnished is true and accurate to the best of my knowledge. I AUTHORIZE the disclosure of this information as needed for the proper investigation and enforcement of my complaint. I UNDERSTAND my identity will be kept confidential to the maximum extent possible, consistent with applicable law and a fair determination of my complaint. I also understand it is against the law for my employer to discharge, intimidate, retaliate, coerce or discriminate against me for filing this complaint.

Signed:*