2. Section I:
4. First Name
5. Last Name
7. Address1
9. City
10. State
11. Zip
13. Telephone(Home):
14. Telephone(Work):
16. Email Address:
18. Acessible Format Requirements?
    -- Select One --Large PrintTDDAudio Type
19. Other
21. Section II:
23. Are you filling this complaint out on your own behalf?
    -- Select One --YES*NO
25. *If you answered "yes" to this question go to, section III.
27. If you answered "no", please supply the name and relationship of the person for whom you are complaining:
29. Please explain why you have filed for a third party:
31. Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.
    -- Select One --YesNo
33. Section III:
35. I believe the discrimination I experienced was based on(check all that apply):

    1. Race
    2. Color
    3. National Origin
    4. Disability
37. Other:
39. Date of Occurrence:
40. Time of Occurrence:
41. Bus #/ Route Name/ #:
43. Location of Incident:
44. Mobility Aid Used (if any):
46. If above information is unknown, please provide other descriptive information to help identify the employee:
48. Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons who were involved. Include name and contact information of the person(s) who discriminated against you (if known) as well as names and contact information of any witnesses.
50. Section IV:
52. Have you previously filed a complaint with this agency?
    -- Select One --YesNo
54. Have you filed this complaint with (if yes) check all that apply and list agency/court:

    1. Federal Agency
    2. Federal Court
    3. State Court
    4. State Agency
    5. Local Agency
56. Please provide information about a contact person at the agency/court where the complaint was filed.
58. Agency:
59. Name:
61. Title:
63. Address:
65. Telephone:
67. Section V: Follow up
69. May we contact you for more details or information regarding this complaint?
    -- Select One --YesNo
70. If yes, what is the best way to reach you? (Choose one)*

    1. Phone
    2. Email
    3. Mail
72. If a phone call is preferred, what is the best day and time to reach you?
74. Please attach any written materials or other information that you think is relevant to your complaint.
76. Signature
77. Date
79. ***Signature and date required.
81. You may also submit this form in person or by paper mail to
    City of Lancaster, Service Safety Director, 104 East Main Street, Lancaster Ohio, 43130
Leave This Blank:


83. 1. Receive an email copy of this form.
84. Email address

    This field is not part of the form submission.

85. Submit Submit and Print

* indicates a required field