Complaint Form - Brazos Transit District

Type of Complaint *

This is a general complaint.
This is a Title VI complaint.
This is an ADA complaint.

Is this a Title VI complaint? (Read more about Title VI here.) Or a general complaint?

ADA Complaint Form

Please note, this form should only be used to report ADA (Americans with Disabilities Act) complaints. If this is not a ADA complaint, please click "This is a general complaint" above to fill out our general complaint form instead.

To expedite the complaint process, please fill out as much as possible. You may complete the form online (below) or print the ADA Complaint form (available in .docx format here, or as a PDF here) and mail it to us at the address shown on the form.

Title VI Complaint Form

Please note, this form should only be used to report Title VI complaints. If this is not a Title VI complaint, please click "This is a general complaint" above to fill out our general complaint form instead.

To expedite the complaint process, please fill out as much as possible. You may complete the form online (below) or print the Title VI Complaint form (available in .docx format here, or as a PDF here) and mail it to us at the address shown on the form.

Section I

Your Name *

Address *

Street Address City State ZIP Code

Your Email

Home Phone with Area Code *

Work Phone with Area Code

Accessible Format Requirements?

Large Print
TDD
Audio Tape
Other

If other accessible format requirements, please explain: *

Section II

Are you filing this complaint on your own behalf? *

Yes
No

If not, please supply the name and relationship of the person for whom you are complaining: *

Please explain why you have filed for a third party: *

Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party. *

Yes
No

Section III

Were you discriminated against because of: *

Race
National Origin
Color
Other (Explain)

Were you discriminated against because of: *

Disability
Race
National Origin
Color
Other (Explain)

If "other", please explain: *

Date of alleged incident: *

Explain as clearly as possible what happened and how you were discriminated against. Indicate who was involved. Be sure to include the names and contact information of any witnesses. *

Section IV

Have you previously filed a Title VI complaint with this agency? *

Yes
No

Have you previously filed an ADA complaint with this agency? *

Yes
No

Section V

Have you filed this complaint with any other Federal, State, or Local Agency; or with any Federal or State court? *

Yes
No

If Yes, check all that apply: *

Federal agency
Federal court
State agency
State court
Local agency

Please provide information about a contact person at the Federal Agency where the complaint was filed:

Name

Phone

Address

Street Address City State ZIP Code

Please provide information about a contact person at the Federal Court where the complaint was filed:

Name

Phone

Address

Street Address City State ZIP Code

Please provide information about a contact person at the State Agency where the complaint was filed:

Name

Phone

Address

Street Address City State ZIP Code

Please provide information about a contact person at the State Court where the complaint was filed:

Name

Phone

Address

Street Address City State ZIP Code

Please provide information about a contact person at the Local Agency where the complaint was filed:

Name

Phone

Address

Street Address City State ZIP Code

Section VI

Name of agency complaint is against: *

Contact person:

Title:

Phone Number:

Bus #

Route #

Provide any other information relevant to your complaint:

Please confirm: *

I understand that checking this box constitutes a legal signature confirming that the information I have provided above is true and accurate.

General Complaint Form

Your Name

Phone

Email

Comments

Bus #

Route #

Please confirm: *

I understand that checking this box constitutes a legal signature confirming that the information I have provided above is true and accurate.

Name

This field is for validation purposes and should be left unchanged.