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2. First Name*
3. Last Name*
4. Gender:*
   -- Select One --MaleFemaleOther
6. Street*
8. (Apt., Bldg., etc.)
10. City*
11. State*
12. Zip*
14. Home Telephone:*
15. Other Telephone:
16. E-Mail Address:*
18. Do you wish to remain anonymous?*

    1. Yes
    2. No
20. Discrimination alleged (check all that may apply)?*

    1. Race
    2. Color
    3. National Origin
    4. Age
    5. Religion
    6. Disability
    7. Sex/Gender
22. Race of Complainant:*

    1. Black
    2. White
    3. Hispanic
    4. Asian American
    5. American Indian
    6. Alaska Native
    7. Pacific Islander
    8. Other
24. How were you discriminated against?*

    Please explain your complaint as clearly as possible. Include how other persons were treated differently. Use additional sheet(s) if necessary. Attach supporting documents if available.

26. Supporting Documents:
28. Date and place of the alleged discriminatory action(s).*

    Please include the earliest date of discrimination and the most recent date(s) of discrimination.

30. If you feel that you have been retaliated against, separate from the discrimination alleged above, please explain the circumstances below.

    The law prohibits intimidation or retaliation against anyone because they have either taken action, or participated in action, to secure rights protected by the laws. If you feel that you have been retaliated against, separate from the discrimination alleged above, please explain the circumstances above. Describe the action you took which you believe was the cause for the alleged retaliation.

32. Name(s) of individual(s) responsible for the discriminatory action(s).

    Name(s) of person(s) who may be contacted for additional information to support or clarify your complaint. (Attach additional sheets, if necessary).

34. 1. Name
35. Address
36. Telephone
38. 2. Name
39. Address
40. Telephone
42. 3. Name
43. Address
44. Telephone
46. 4. Name
47. Address
48. Telephone
50. What action(s) have you or your representative done to attempt to resolve this complaint?

    1. Filed with the SC Department of Transportation
    2. Filed with the Federal Highway Administration
    3. Filed with the U.S. Department of Transportation
    4. Filed with another Federal agency
    5. Other action
52. Please include filing dates or other dates as applicable that correspond with the numbers above.
54. 1.
    1.
55. 2.
    2.
56. 3.
    3.
58. 4.
    4.
59. 5.
    5.
61. Please provide any additional information you feel would be helpful in investigating this matter.
63. Briefly explain what action you are seeking.*
65. Complainant's Signature:*

    Please type name in the above field.

66. Date:*
    Date:
Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit

* indicates a required field