Official Government Website

WIOA Title I Complaint Form

      Items marked with an asterisk(*) are required.

      Complainant Contact Information

      State Agency you believe has discriminated or retaliated

      Complaint Information

      Witness Information

      If applicable.

      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.

      ver: 3.5.2 | last updated: