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2. Please complete this form if you have a complaint, concern or a compliment.
4. Name
6. Address
8. City
9. State
10. Zip
12. Phone
13. Email
17. Type of Complaint / Comment
19. Type of Complaint

    Select all the apply.

    1. ADA Discrimination: Discrimination Based on a Disability
    2. Civil Rights / Title VI Complaint: Discrimination Based on Race, Color, or National Origin
    3. General Complaint, Concern, or Compliment: Bus Service, Schedule, or Specific Incident
21. Are you filing this on your own behalf?

    1. Yes

    1. No
23. Name of Person for Whom This Form is Submitted
    Please supply the name and relationship of the person for whom you are submitting this claim.
25. Explanation of Filing
    Please explain why you have filed for a third party.
27. Permission of Filing

    1. Yes
    2. No

    Please confirm that you have obtained the permission of the aggrieved party if you are filing on the behalf of a third party.
31. Details of Complaint or Incident
33. Date & Time of Incident
    Date & Time of Incident

    Date & Time of Incident
37. General Complaint, Concern, or Incident
39. Bus Number
40. Route Number
42. Inbound or Outbound

    1. Inbound

    1. Outbound
44. Explain the Incident
48. Civil Rights / Title VI Complaint
50. Kind of Discrimination

    Check the kind of discrimination you are reporting.

    1. Color
    2. National Origin
    3. Race
52. Explain the Incident
    Please be as specific as possible.
54. Persons Involved
    Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all persons involved. Include name and contact information of person(s) who discriminated against you (if known) as well as names and contact information of witnesses.
58. Ada Discrimination: Discrimination Based on a Disability
60. Explanation
    Describe all persons who were involved. include the names and contact information of the person(s) who discriminated against you (if known) as well as the names and contact information of any witnesses.
    
    If this complaint is related to equipment or structures (for example: buses or bus stops), please try to be as specific as possible in identifying which vehicle or locations may be creating the situation.
    
    Explain as clearly as possible what happened and why you believe you were or are being discriminated against based on your disability.
64. Have you previously filed a complaint against this agency?

    1. Yes

    1. No
65. What type of complaint did you file?

    1. ADA
    2. Title VI
    3. Other
67. Complaint Type
    What other type of complaint did you file?
71. Ever filed this complaint with any other Federal, State or local agency, or any Federal or State court?

    1. Yes

    1. No
73. Federal Agency Name
75. State Agency Name
77. Local Agency Name
79. Federal Court Name
81. State Court Name
83. Contact Person
    Please provide information about a contact person at the agency / court where the complaint was filed.
87. Additional Comments
89. Name*
91. Email or Phone*
93. Additional Comments
95. Acknowledgement*

    Buy submitting this form you are stating that the information you provided is true and accurate to the best of your knowledge. You are also giving METRO and it's agents the right to verify any and all information.

    1. I agree
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97. 1. Receive an email copy of this form.
98. Email address

    This field is not part of the form submission.

99. Submit

* indicates a required field