Title VI Online Complaint Form

Керівний комітет

Today's Date

День

Місяць

Рік

First name

Last name

Phone

Address

Date(s) of alleged discrimination

Describe the alleged discriminatory act(s) or practice(s) in detail

Identify the individual(s) or department(s) involved, if known

Have you contacted anyone within MVP regarding this matter? If yes, please provide details

Please describe any witnesses or individuals who have knowledge of the alleged discrimination. Provide names and contact information, if possible

Please provide any additional information or documentation that may be relevant to your complaint

Have you previously filed a complaint with MVP or any other entity regarding a similar issue? If yes, please provide details

Are there any accommodations or assistance you require during the investigation of this complaint?

I certify that the information provided in this complaint is true and accurate to the best of my knowledge. I understand that MVP will investigate based on the information provided. I agree to cooperate fully in the investigation.