Title VI Complaint Form

Please note!

Under Title VI of the 1964 Civil Rights Act (as amended) and related statues, the City of Phoenix must ensure that no person shall, on the basis of race, color or national origin be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.

To file a complaint online, please complete and then submit this form. It is pre-addressed to arrive at the correct destination when you click on the “Submit” button below.

If you have questions or comments about the process, or want to email the ADA/Title VI Coordinator directly , please use this email address: PHXTransitEO@phoenix.gov.

In order for us to respond to your message appropriately, please fill in as much of the following information in this form on this page as possible.

A city staff person will contact you as soon as possible after you submit this form.

Please wait while your form is submitted.

*denotes required field

Incident Information *

Customer Information

First Name: *

Last Name: *

Middle Initial:

Address: *

City: *

State: *

Zip: *

Phone: *

Email: *

Incident Information

Time of Incident: * (Please enter in format: HH:MM AM/PM)

Date of Incident: * (Month, Date, Year; i.e. Jan. 1, 2019)

City Where Incident Occurred: *

Major Crossroads: *

Crossroad One:

Crossroad Two:

Direction of Travel: *

Service Type: *

Route and/or Vehicle Number:

Operator and Vehicle Information:

Operator Name and/or Description:

Additional Vehicle Information:

Complaint Details

What was the discrimination based on? (Check all that apply): *
Race
Color
National Origin
Other
If Other, please provide more information:

Please describe the incident and provide details about why you believe you were discriminated against. Please describe all persons involved in the incident, including the name(s) and contact information of the person(s) who discriminated against you, and names and contact information of any witnesses. *

Additional Complaint Information

Have you filed a complaint about this incident with the Federal Transit Administration (FTA) or Valley Metro? *
Yes (Please enter provide details below.)
No

Please provide Complaint Number(s) and/or Contact(s) from Either Agency:

Attachments

Please attach any additional material that is relevant to your complaint.

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Electronic Signature *

Signature: *

Please enter your full legal name above. This will be considered your signature.

Title VI Complaint Form

Incident Information *

Customer Information

Incident Information

Major Crossroads: *

Complaint Details

Additional Complaint Information

Attachments

Please attach any additional material that is relevant to your complaint.

The combined size of all uploaded files is limited to 20MB.

Electronic Signature *

Review

Thank you for your submission!

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