710.1E2 Child Nutrition Programs Civil Rights Complaint Form

Complaint Contact Information:

 

Name: _______________________________________________________________________________

Street Address, City, State, Zip: ____________________________________________________________

County: _______________________ Area Code/Phone: ________________________________________

Email Address: _________________________________________________________________________

 

Complaint Information:

 

1. Specific name and location of the entity and individual delivering the service or benefit: ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

2. Describe the incident or action of the alleged discrimination or give an example of the situation that has discriminatory effect on the public, potential program participants, or current participants. ___________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

3. On what basis does the complainant feel discriminated exists (race, color, national origin, sex, age, disability, creed, sexual orientation, religion, gender identity, political party affiliation, actual/potential parental/family/marital status)? ______________________________________

______________________________________________________________________________

______________________________________________________________________________

4. List the names, titles, and business addresses of the persons who may have knowledge of the alleged discriminatory action: _____________________________________________________

______________________________________________________________________________

______________________________________________________________________________

5. List the dates during which the alleged discriminatory actions occurred, or if continuing, the duration of such actions: __________________________________________________________
6. Date Complaint received: _________________________________________________________
7. Person receiving complaint: _______________________________________________________
8. Actions Taken: __________________________________________________________________

______________________________________________________________________________

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, age, and disability for complaints received within 180 days. Civil rights complaints must be submitted to the USDA Office of Civil Rights within five calendar days of receipt and no later than 180 days of the discriminatory act. The link for submission of a complaint is: program.intake@usda.gov 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, Grimes State Office building, 400 E. 14th St. Des Moines, IA 50319-1004; phone number 515-281-4121, 800-457-4416; website: https://icrc.iowa.gov/.

 

Approved January 8, 2024

Reviewed December 11, 2023

Revised