Pitt County Forms Center

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   1717 W. 5th Street Greenville, NC 27834  |  Telephone: (252) 902-2002
   pitt.pats@pittcountync.gov

   Discrimination Complaint Form
    

4. Any person who believes they have been subjected to discrimination based on race, color, creed, sex, age, national origin, or disability may file a written complaint with Pitt Area Transit System (PATS) within 180 days of the occurrence.
6. Last Name*
7. First Name*
9. Address*
11. City*
12. State
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
13. Zip Code*
15. Home Phone Number*
16. Work Phone Number
17. Email Address
19. Identify the Category of Discrimination*

    Note: Title IV bases are race, color, national origin. All other bases are found in the "Nondiscrimination Assurance" of FTA certifications & Assurances.

    1. Race
    2. Creed (Religion)
    3. Color
    4. Disability

    1. National Origin
    2. Limited English Proficiency
    3. Age
    4. Sex
20. Identify the race of complainant
    -- Select One --Alaskan NativeAmerican IndianAsian AmericanBlackHispanicPacific IslanderWhiteOther
22. Date and place of alleged discriminatory action(s). Please include the earliest and most recent dates of discrimination.*
24. Names of individuals responsible for the discriminatory action(s).
26. Describe the nature of the action, decision, or condition of the alleged discrimination. Explain as clearly as possible what happened and why you believe your protected status (basis) was a factor in the discrimination. Include how other persons were treated differently from you. (Attach additional pages or documentation if necessary.)
28. The law prohibits intimidation or retaliation against anyone who has taken action or participated in action to secure rights protected under these laws. If you believe you have been retaliated against, separate from the discrimination alleged above, please explain the circumstances below. Describe the action you took that you believe led to the alleged retaliation. (Attach additional page(s) if necessary.)
30. Names of persons (witnesses, fellow employees, supervisors, or others) whom we may contact for additional information to support or clarify your complaint. (Attach additional page(s) if necessary.)
32. 1 - Witness Name | Address | Phone Number
34. 2 - Witness Name | Address | Phone Number
36. 3 - Witness Name | Address | Phone Number
38. Have you filed, or intend to file a complaint regarding the matter raised with any of the following?*

    Check all that apply.

    1. No, Have not filed, or intend to file
    2. NC Department of Transportation
    3. Federal Transit Administration

    1. US Department of Transportation
    2. US Department of Justice

    1. Federal or State Court
    2. Other
40. If Other and or Yes, please provide "other" name and filing dates.
42. Have you discussed the complaint with any PATS representative?*
    -- Select One --YesNo
44. If Yes, please provide the name, position and date of the discussion.
46. Please provide information that you believe would assist with an investigation. (Attach additional page(s) if necessary.)*
48. Briefly explain what remedy or action you are seeking for the alleged discrimination.*
50. Address*
52. Phone Number
53. Email Address
55. Please print after completion, sign and date. We cannot accept any unsigned complaint.
57. Complaintant Signature Requires
58. Date*
60. Please Mail Complaint Form To: Pitt Area Transit System - 1717 W. 5th Street Greenville, NC 27834
62. For Office Use Only
64. Date received
65. Case #
66. Processed by
68. Referred to

    1. NC Department of Transportation

    1. Federal Transit Administration
69. Date Referred
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70. Print Only

* indicates a required field