DISCRIMINATION COMPLAINT AGAINST THE BOSTON REGION METROPOLITAN PLANNING ORGANIZATION

 

If you need assistance completing this form, please contact CTPS

at (617)973-8495.

 

Complainant Contact Information

               Name:  _____________________________________________________

           Address:  _____________________________________________________

        City/Town:  ______________________________ State:          _____ Zip: _________

  Home phone:  ________________________ Work phone: __________________

              E-mail:  _____________________________________________________

 

Complaint

Date of alleged incident: ____________________________________________

Decision, document, statement, or other act that you believe was discriminatory: ___________________________________________________________________________________________________

If you believe that one or more MPO employees discriminated against you, name of employee(s), if known:_____________________________________________________________________________________________

Basis of alleged discrimination: 

□   Race                       □   Age                       □   Ancestry

□   Color                       □   Disability             □   Sexual orientation

□   National origin      □   Income                □   Gender identity or expression

□   Language              □   Religion               □   Other:___________

□   Gender                   □   Military service   

Describe the nature of the incident. Explain what happened and the allegedly discriminatory action(s). Indicate who was involved. Include how other people were treated differently, if present, or how you believe others would have been treated differently if they had been present. Attach any written or graphic material or other information pertaining to the complaint.

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List names and contact information of anyone who may have knowledge of the alleged discrimination.

 

          Name:      _____________________________________________________

      Address:      _____________________________________________________

    City/Town:      ______________________________ State:          _____ Zip: _________

Home phone:    ________________________ Work phone: __________________

          E-mail:      _____________________________________________________

 

          Name:      _____________________________________________________

      Address:      _____________________________________________________

    City/Town:      ______________________________ State:          _____ Zip: _________

Home phone:    ________________________ Work phone: __________________

          E-mail:      _____________________________________________________

 

          Name:      _____________________________________________________

      Address:      _____________________________________________________

    City/Town:      ______________________________ State:          _____ Zip: _________

Home phone:    ________________________ Work phone: __________________

          E-mail:      _____________________________________________________

 

How do you think this issue can be resolved?

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

 

In the course of conducting a thorough complaint review process, it may become necessary to disclose your name to persons other than those conducting the review. To allow this, sign, date, and submit the consent/release form, enclosed for your convenience.

This discrimination complaint form must also be signed and dated below.

 

I certify that to the best of my knowledge the information I have provided is accurate and the events and circumstances occurred as I have described them.

 

Signature:  ______________________________    Date:  __________________

 

Attachments:   □  Yes     □  No

 

Please submit complaint form, consent/release form, and any additional information to:

 

Mr. Richard A. Davey, Chair

Boston Region Metropolitan Planning Organization

State Transportation Building

10 Park Plaza, Suite 2150

Boston, MA 02116-3968