Discrimination Complaint Form

Please provide the following information in order for us to process your complaint. This form is available in alternate formats and multiple languages. Should you require these services or any other assistance in completing this form, please let us know.




Telephone Numbers: (Home)____________(Work)____________(Cell)____________

Email Address:_________________________________________________________


Please indicate the nature of the alleged discrimination:

Categories protected under Title VI of the Civil Rights Act of 1964:

Race    Color    National Origin (including limited English Proficiency)

Additional categories protected under related Federal and/or State laws/orders: 

Disability  Age  Sex  Sexual Orientation  Religion  Ancestry

Gender  Ethnicity  Gender Identity  Gender Expression  Creed  Veteran’s Status  Background 


Who do you allege was the victim of discrimination?

You    A Third Party Individual    A Class of Persons


Name of individual and/or organization you allege is discriminating:



Do you consent to the investigator sharing your name and other personal information with other parties to this matter when doing so will assist in investigating and resolving your complaint?

Yes    No

Please describe your complaint. You should include specific details such as names, dates, times, witnesses, and any other information that would assist us in our investigation of your allegations. Please include any other documentation that is relevant to this complaint. You may attach additional pages to explain your complaint.



Have you filed this complaint with any other agency (Federal, State, or Local)?

Yes    No

If yes, please identify:____________________________________________________


Have you filed a lawsuit regarding this complaint?

Yes    No

If yes, please provide a copy of the complaint.



Signature: ____________________________________ Date:___________________



Mail to:     



Email to:



Title VI Specialist, Boston Region Metropolitan Planning Organization, 10 Park Plaza, Suite 2150, Boston, MA 02116



Title VI Coordinator, MassDOT Office of Diversity and Civil Rights, Suite 3800, 10 Park Plaza, Boston, MA 02116