CHILD NUTRITION PROGRAMS CIVIL RIGHTS COMPLAINT FORM

COMPLAINT CONTACT INFORMATION:

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Email *

County

Phone

COMPLAINT INFORMATION:

SPECIFIC NAME AND LOCATION OF THE ENTITY AND INDIVIDUAL DELIVERING THE SERVICE OR BENEFIT:

ON WHAT BASIS DOES THE COMPLAINANT FEEL DISCRIMINATION EXISTS (race, color, national origin, sex, age, disability, creed, sexual orientation, religion, gender identity, political party affiliation, actual/potential parental/family/marital status)?

DESCRIBE THE INCIDENT OR ACTION OF THE ALLEGED DISCRIMINATION OR GIVE AN EXAMPLE OF THE SITUATION THAT HAS A DISCRIMINATORY EFFECT ON THE PUBLIC, POTENTIAL PROGRAM PARTICIPANTS, OR CURRENT PARTICIPANTS:

LIST THE NAMES, TITLES, AND BUSINESS ADDRESSES OF PERSONS WHO MAY HAVE KNOWLEDGE OF THE ALLEGED DISCRIMINATORY ACTION:

PROVIDE ANY ADDITIONAL INFORMATION RELATED TO THE ALLEGED DISCRIMINATION. COMPLAINANT MAY PASTE PICTURES, TABLES, ETC. INTO THE SPACE BELOW OR ATTACH DOCUMENTS RELEVANT TO THE COMPLAINT

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LIST THE DATE(S) DURING WHICH THE ALLEGED DISCRIMINATORY ACTIONS OCCURRED, OR IF CONTINUING, THE DURATION OF SUCH ACTIONS:

DATE COMPLAINT RECEIVED:

PERSON RECEIVING THE COMPLAINT:

ACTION(S) TAKEN:

Phone

USDA is the cognizant agency for the Child Nutrition Programs listed and therefore is the first contact for the six protected classes of race, color, national origin, sex (including gender identity and sexual orientation), age, and disability for complaints received within 180 days. A complainant has 180 days from the date of the alleged discriminatory act to submit a complaint. The complaint must be submitted to the Food and Nutrition Services (FNS) Civil Rights Division (CRD) within 5 calendar days of receipt by the State or local office. The email address for submission of a complaint is: program.intake@usda.gov or USDA, Office of the Assistant Secretary for Civil Rights, 1400 Independence Ave, SW, Stop 9410, Washington, D.C. 20250-9410. In addition to sending the complaint to USDA, the SFA is required to send a copy of the complaint to the State agency.

In Iowa, protected classes also include sexual orientation, gender identity, religion or creed and complaints can be filed up to 300 days of occurrence. The address for Iowa complaints is: Iowa Civil Rights Commission, 6200 Park Ave, Suite 100, Des Moines, IA 50321; phone number 515-281-4121, 800-457-4416; website: https://icrc.iowa.gov/.

This institution is an equal opportunity provider.

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