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710.1E2 CHILD NUTRITION PROGRAMS CIVIL RIGHTS COMPLAINT FORM

710.1E2 CHILD NUTRITION PROGRAMS CIVIL RIGHTS COMPLAINT FORM

 

Complain Contact Information:

 

Name:  _______________________________________________________________________

Street Address, City, State, Zip:  ___________________________________________________

County:  __________________________________Area Code/Phone:  ____________________

Email Address:  ________________________________________________________________

 

Complaint information:

 

  • Specific name and location of the entity and individual delivery the service or benefit

 

 

  • 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:

 

 

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

 

 

  • Lis the names, titles, and business addresses of persons who may have knowledge of the alleged discriminatory action:

 

 

  • Date complaint received:  ___________________________________________________

 

 

  • Person receiving complaint:  _________________________________________________

 

 

  • 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 thatn 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, gendr 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, Grims 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/

 

 

This institution is an equal opportunity provider.