Home | CVAD-Grants Manual | Chapter 24 Civil Rights/Complaint Process | Service Standards Online Complaint Form

Service Standards Complaint Form

The purpose of this form is to assist you in filing a complaint regarding an alleged violation of service standards with the Crime Victim Assistance Division in connection with one of its subrecipient’s programs or services.

* Indicates a required field

Step 1

Step 2

Submitter Name (First and Last):

Submitter Street Address:

Submitter City:

Submitter State:

Submitter Zip Code:

Submitter Home Telephone:

Submitter Work Telephone:

Other Submitter Telephone:

Submitter Email Address:

Organization/Person(s) discriminated against, if different from above

Is this discrimination complaint about you:

Yes, this complaint is about me.

No, this complaint is not about me.

Agency and department or program complaint against

Agency and Department/Program Name:

Agency Address:

Agency City:

Agency State:

Agency Zip Code:

Agency Home Phone:

Agency Work Phone:

Other Agency Phone: