Encuesta de información

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Today's Date *:	Today
Contact Information
(Please note: If you do not provide contact information, we will not be able to inform you of the steps we are taking to respond to your complaint.):
First Name:
Last Name:
Phone Number:	( ) - Second three digits Last four digits
Email:
How would you prefer to be contacted if more information is needed?:	Email Phone Mail
Is somebody else helping you fill out this form? *:	Yes No
First Name:
Last Name:
Phone Number:	( ) - Second three digits Last four digits
Email:
What language would you prefer to receive written information in? *:	English Spanish Vietnamese Portuguese Haitian Creole Garifuna K’iche Russian French Arabic Other
What language would you prefer to receive spoken information in? *:	English Spanish Vietnamese American Sign Language Portuguese Haitian Creole Garifuna K’iche Russian French Arabic Other
Complaint Details
Please describe what happened *:	Include as much as detail as possible, including the name(s) and/or position(s) of any relevant individuals involved and the services/information you were seeking
Which services did this incident affect your access to? :
Where did this incident occur? *:	In-person Online Over the Phone Other
What language(s) did you need services in? *:
Language access issues: *:	I was not informed of the availability of language access services Lack of translated publicly-posted signage regarding language access services I needed an interpreter and did not receive one The interpreter’s skills were not good/they were not proficient in my language The interpreter was not certified The interpreter made rude or inappropriate comments I was told to bring my own interpreter I was not given forms, documents, or notices in my preferred language Translated forms, documents, or notices in my preferred language were poor quality I was treated unfairly due to limited English proficiency I was unable to access services, programs, or activities I waited too long for services Other (select all that apply)
Did this incident happen more than once?*:	Yes No
Date of incident *:	Today
Time of incident:	(approximate, if unknown)
Which of the following did this incident directly impact *:	Preparing before an emergency or disaster Safety and response during an emergency or disaster Recovery after an emergency or disaster (select all that apply)
Did you inform staff from this department/agency that you needed assistance in your language? *:	Yes No
If yes, please describe how you asked for assistance and/or who you spoke to:
If applicable, what response did you receive when asking for assistance?:
What actions would you like to see taken to resolve this issue?:
Upload any relevant photos or documents to further explain complaint: