SamTrans ADA Discrimination Complaint Form

SamTrans does not discriminate against individuals with disabilities in the provision of transportation services and is committed to ensuring that no person, solely by reason of his or her disability, is excluded from participation in, is denied benefits of, or is subjected to discrimination under any SamTrans programs or activities. Any person who believes they have been discriminated against based on disability may file a complaint. Complaints must be filed within 180 calendar days of the incident.

Within 10 working days of receipt of your completed complaint form, SamTrans will contact you to confirm receipt of your complaint form and begin an investigation (unless the complaint is filed with an external entity first or simultaneously). The investigation may include discussion(s) of the complaint with all affected parties to determine the nature of the problem. The investigation generally will be conducted and completed within 60 days of receipt of a complete complaint form. Based upon all information received, an investigation report will be submitted to a SamTrans department Director. The complainant will receive a letter stating the SamTrans final decision by the end of the 60-day time limit.

Please complete the information below and send to:

SamTrans, ADA Coordinator
Accessible Transit Services
166 N. Rollins Rd
Millbrae, CA 94030
or: dubostc@samtrans.com

SECTION 1 - CONTACT INFORMATION

Name:

Address:

City:

State:

ZIP:

Phone:

(Home)

(Cell)

(Work)

[Please note if any of the phone numbers are for a TDD or TTY.]

Email:

SECTION 2 – FILING FOR ANOTHER PERSON

Are you filing this complaint on your own behalf

Yes

[If you answered "yes" to this question, go to Section 3.]

If not, please supply the name and relationship of the person for whom you are filing the complaint:

Please explain why you have filed for a third party.

Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.

Yes

SECTION 3 – DISCRIMINATION COMPLAINT

Please describe the disability of the aggrieved party

Date and time the alleged discrimination took place:

Where did the alleged discrimination take place? Specific vehicle information is helpful (e.g. vehicle number).

Is there a person you can identify who discriminated against the aggrieved party?

Name:

ID#

In your own words, describe the alleged discrimination. Explain what happened and who you believe was responsible.

SECTION 4 – PREVIOUS OR EXISTING COMPLAINTS & LAWSUITS

Have you previously filed an ADA discrimination complaint with SamTrans?

Yes, for this incident

Yes, for a different incident

Have you filed this complaint with any other agencies or a court?

Federal Agency

Federal court

State Agency

State court

Local Agency

Other…

Have you filed a claim or lawsuit regarding this complaint?

Yes

If yes, please provide a copy of the complaint form and note court where filed:

Federal Court

State Court

Please provide contact person information for the agency/court where the complaint was filed.

Name / Office:

Address

City:

State:

ZIP Code:

Phone Number

SECTION 5 – SIGNATURE

Please sign below to attest to the truthfulness of the above. You may attach any written materials or other information that you think is relevant to your complaint.

Complainant’s Signature

Sign above

Date

Note: A complaint also may be filed with: Federal Transit Administration, Office of Civil Rights, 1200 New Jersey Ave., SE, Washington, DC 20590.

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