Policy 710.1E2 CHILD NUTRITION PROGRAMS CIVIL RIGHTS COMPLAINT FORM
Complaint 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 delivering 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, disability, age, marital status, family/parental status, income derived from public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, , creed, sexual orientation, religion, actual/potential parental/family/marital status)?
List the names, titles, and business addresses of persons who may have knowledge of the alleged discriminatory action:
List the date(s) during which the alleged discriminatory actions occurred, or if continuing, the duration of such actions:
Date complaint received:
Person receiving complaint:
Action(s) taken:
USDA is the cognizant agency for the Child Nutrition Programs listed and therefore is the first contact for the following protected classes of race, color, national origin, religion, sex, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity 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 Iowa, additional protected classes also include actual or potential parental, family, or marital status, sexual orientation, and creed 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 number 515-281-4121, 800-457-4416; website: https://icrc.iowa.gov/.
This institution is an equal opportunity provider.12/2021
Approved: 07-11-22 Reviewed: 3-9-26 Revised:3-9-26
