Federal Transit Administration

Office of Civil Rights
Complaint Form

 

Section I

Name:_________________________________________

Address:_________________________________________________

Telephone Numbers: 

(Home)_______________(Work)_________________

Electronic Mail Address:___________________________

Accessible Format Requirements?

Large Print _______ Audio tape _____

TDD ___________ Other________________________________________

 

The Federal Transit Administration (FTA) Office of Civil Rights is responsible
for civil rights compliance and monitoring, which includes ensuring that
providers of public transportation properly implement Title II of the
Americans with Disabilities Act of 1990 (the ADA), the Department of
Transportation (DOT) ADA regulations, and Section 504 of the Rehabilitation
Act of 1973. In the FTA complaint investigation process, we analyze the
complainant's allegations for possible ADA deficiencies by the transit provider.
If deficiencies are identified they are presented to the transit provider and
assistance is offered to correct the inadequacies within a predetermined
timeframe. FTA also may refer the matter to the U.S. Department of
Justice for enforcement.
 

Section II

Are you filing this complaint on your own behalf?

Yes ____ No ____

[If you answered "yes" to this question, go to Section III.]

If not, please supply the name and relationship of the person
for whom you are complaining: _________________________________________________

Please explain why you have filed for a third party. _______________________ _______________________________________________________________

Please confirm that you have obtained the permission of the aggrieved party
if you are filing on behalf of a third party. 

Yes ____ No ____

 

Section III

Have you previously filed an ADA complaint with FTA? Yes____ No___

If yes, what was your FTA Complaint Number? _____________

[Note: This information is needed for administrative purposes;
we will assign the same complaint number to the new complaint.]

Have you filed this complaint with any of the following agencies? 

Transit Provider _____ Department of Transportation ____

Department of Justice_____ Equal Employment Opportunity Commission _____

Other _____________________________________________

Have you filed a lawsuit regarding this complaint? Yes_____ No____

If yes, please provide a copy of the complaint form.

[Note: This above information is helpful for administrative tracking purposes.
However, if litigation is pending regarding the same issues, we defer to
the decision of the court.]

 

Section IV

Name of public transit provider complaint is against:

__________________________________________________________

Contact person: _________________________ Title: ___________________

Telephone number: ________________________________________

On separate sheets, please describe your complaint. You should include specific
details such as names, dates, times, route numbers, witnesses, and any other information that would assist us in our investigation of your allegations.
Please also provide any other documentation that is relevant to this complaint. 

 

Section V

May we release a copy of your complaint to the transit provider?  Yes ____ No ____
May we release your identity to the transit provider?  Yes ____ No ____

Please sign here: _____________________________________________
Date: ________________________
[Note - We cannot accept your complaint without a signature.]

Please mail your completed form to:

Director
FTA Office of Civil Rights
400 7th Street, S.W., Room 9102
Washington, D.C. 20590

You may also contact us by phone at our toll free FTA ADA Assistance Line,

1-888-446-4511, TDD 1-202-366-0153, or
through the Federal Information Relay Service, 1-800-877-8339.
We can also be reached by electronic mail at: ada.assistance@fta.dot.gov.
The FTA Web Page can be found at [http://www.fta.dot.gov].
 

Outside Links will Open Up in a New Window
contact us: DBTAC Southwest ADA Center
800-949-4232 or 713-520-0232 v/tty