Minnesota Department of Transportation

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Civil Rights

Committed to equality in transportation service

Title VI discrimination complaint form

Please complete this form if you feel that you have experienced discrimination by the Minnesota Department of Transportation (MnDOT), its sub-recipients, consultants, or contractors on the basis of race, color, national origin, sex, age, income status, religion, or disability, in violation of the Title VI Act of 1964 and related statutes. The complaint must be filed no later than 180 calendar days of the alleged discriminatory incident.

This form is available in English, Spanish, Hmong, and Somali. Requests for alternative formats or additional languages of the complaint form should be directed to ADArequest.dot@state.mn.us or by phone at 651-366-4718 or TTY 800-627-3529.

MnDOT Title VI discrimination complaint form

Personal information



Basis of the discrimination

I believe I was discriminated against based on my (check all that apply):












Information of agency, business or contractor that allegedly discriminated










Tell us what happened


What is your desired outcome?


Verification

In signing this complaint, I verify that, to the best of my knowledge, everything I have stated in this form is accurate and true.



Privacy notice: MnDOT is asking you to provide information in this complaint form which includes private and/or confidential information under the Minnesota Government Data Practices Act. MnDOT is asking for this private/confidential information so that it can investigate and respond to allegations of discrimination. You are not legally required to provide this information. However, if you do not provide sufficient information, MnDOT may not be able to properly investigate your complaint. The information you provide will be used by MnDOT employees whose job assignments reasonably require access to the information. The following also have a legal right to access the information: exclusive representative for any MnDOT employee who becomes the subject of investigation in connection with your complaint; the arbitrator if discipline imposed on any such employee is appealed to arbitration; the MN Attorney General’s Office; the MN Legislative Auditor’s Office; law enforcement agencies and prosecutorial authorities; persons/entities named pursuant to court order; persons/entities whom you authorize; and any other person or entity authorized by state or federal law.