702.1-E2 - Child Nutrition Programs Civil Rights Complaint Form

Click here to download the Child Nutrition Programs Civil Rights Complaint Form

COMPLAINT CONTACT INFORMATION

Name: 
Address, City, State, Zip: 
County:
Phone:
Email: 

COMPLAINT INFORMATION

1. Specific name and location of 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 a discriminatory effect on the public, potential program participants, or current participants:
3. On what basis does the complainant feel discrimination in accordance with applicable federal and/or state laws exists (race, color, national origin, sex, age, disability, creed, sexual orientation, religion, political party affiliation, actual/potential parental/family/marital status):
4. List the names, titles, and business addresses of 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. Action(s) taken:

The 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 accordance with applicable federal and/or state laws protected classes also include sexual orientation, 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 Avenue, Suite 100, Des Moines, IA 50321-1270; phone numbers 515-281-4121 or 800-457-4416; website https://icrc.iowa.gov/.

This institution is an equal opportunity provider.