DISCRIMINATION COMPLAINT AGAINST THE BOSTON REGION METROPOLITAN PLANNING ORGANIZATION
If you need assistance completing this form, please contact CTPS
at (617)973-8495.
Name: _____________________________________________________
Address: _____________________________________________________
City/Town: ______________________________ State: _____ Zip: _________
Home phone: ________________________ Work phone: __________________
E-mail: _____________________________________________________
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?
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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.
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