Any individual, group of individuals or entity that believes they have

GREATER SOUTHEAST MANAGEMENT DISTRICT TITLE VI COMPLAINT PROCEDURES
Any individual, group of individuals or entity that believes they have been subjected to
discrimination on the basis of race, color, or national origin, as prohibited by Title VI
nondiscrimination provisions by GSMD, may file a written complaint. A formal complaint must
be filed within 180 calendar days of the alleged occurrence, or when the alleged discrimination
became known to the complainant. The complainant must meet the following requirements:
a. Submit the complaint in writing and signed by the complainant(s).
b. Present the date of the alleged act of discrimination (date when the complainant(s)
became aware of the alleged discrimination; or the date on which that conduct was
discontinued or the latest instance of the conduct).
c. Present a detailed description of the issues including name(s) and job(s).
Allegations received by fax or email will be acknowledged and processed, but a signed, original
copy of the complaint with the identity(ies) of the complainant(s) and the intent is required to be
mailed to GSMD to be able to process it. Allegations received by telephone will be put into
writing and provided to the complainant for confirmation or revision before processing. A
complaint form will be forwarded to the complainant for him/her to complete, sign, and return to
GSMD for processing.
GSMD will process all complaints that are completed and submitted in a timely manner. Once
the complaint is received, GSMD will review it to determine if GSMD has jurisdiction.
Complaints will be reviewed for:
a. Allegations involving discrimination based on race, color, or national origin;
b. Allegations involving a program or activity of a federal funding recipient, subrecipient, or contractor;
c. The complainant(s) acceptance of reasonable resolution based on GSMD’s
administrative authority.
A complaint may be dismissed if the Complainant requests the withdrawal of the complaint; fails
to respond to repeated requests for additional information needed to process complaint; and/or
cannot be located after reasonable attempts.
GSMD has authority for accepting complaints for investigation. Once GSMD decides to proceed
with the investigation, the complainant will be notified in writing of the determination within ten
(10) calendar days. The complaint will receive a case number and then be logged into GSMD’s
records identifying its basis (race, color, or national origin) and alleged harm.
In cases where GSMD assumes investigation of the complaint, GSMD will provide the
individual(s) identified in the complaint with the opportunity to respond to the allegations in
writing. The identified individual(s) will have ten (10) calendar days from the date of GSMD’s
written notification of acceptance of the complaint to furnish his/her response to the allegations.
Within 40 calendar days of the acceptance of the complaint, GSMD will prepare an investigative
report for the GSMD Executive Director. The report shall include a narrative description of the
incident, identification of persons interviewed, findings, and recommendations for disposition.
The GSMD Executive Director will have ten (10) calendar days to review and provide
comments.
GSMD will address any comments to the preliminary investigative report, and its findings will
be forwarded to GSMD’s legal staff for review. The legal staff will review the report and
associated documentation and will provide input within ten (10) calendar days. There will be a
period of ten (10) calendar days for the legal staff to discuss the report and any recommendations
with the Title VI Coordinator, and have the Title VI Coordinator address any modifications as
needed.
GSMD’s final investigative report and a copy of the complaint will be forwarded to FTA within
60 calendar days of the acceptance of the complaint. GSMD will notify the parties of its
findings.
TITLE VI COMPLAINT FORM
The Greater Southeast Management District is committed to ensuring that no person is
excluded from participation in or denied the benefits of its services on the basis of race, color, or
national origin, as provided by Title VI of the Civil Rights Act of 1964, as amended. Title VI
complaints must be filed within 180 days from the date of the alleged discrimination.
The following information is necessary to assist us in processing your complaint. If you require
any assistance in completing this form, please contact the Program Manager for GSMD by
calling 713-942-0500. The completed form must be returned to the Greater Southeast
Management District, 5445 Almeda, Suite #503, Houston, Texas 77004.
Your Name:
Phone:
Street Address:
Alt Phone:
City, State & Zip Code:
Person(s) discriminated against (if someone other than
complainant): Name(s):
Street Address, City, State & Zip Code:
Which of the following best describes the reason
for the alleged discrimination took place?
(Circle one)
 Race
 Color
 National Origin (Limited English
Proficiency)
Date of
Incident:
Please describe the alleged discrimination incident. Provide the names and title of all GSMD
employees involved if available. Explained what happened and whom you believe was
responsible. Please use the back of this form if additional space is required.
T I T L E VI C O M P L A I N T F O R M
The Greater Southeast Management District
Please describe the alleged discrimination incident (continued)
Have you filed a complaint with any other federal, state or local agencies? (Circle one) Yes / No If
so, list agency / agencies and contact information below:
Agency:
Contact Name:
Street Address, City, State & Zip Code:
Phone
Agency:
Contact Name:
Street Address, City, State & Zip Code:
Phone
Complainants Signature:
Date:
______________________________________________________________________________
Print or Type Name of Complainant
Date Received:
Review By:
F O R M U L A R I O D E Q U E J A S D E L T Í T U L O VI
El Distrito Administrativo de Greater Southeast (GSMD) esta comprometida a garantizar que ninguna
persona sea excluida de participar o se le sean negados los beneficios de sus servicios sobre la base de
raza, color u origen nacional, conforme a lo dispuesto por el Título VI del Acta de Derechos Civiles de
1964. Las quejas conforme al Título VI deben ser presentadas dentro de los 180 días siguientes a la
fecha de la supuesta discriminación.
La siguiente información es necesaria para ayudarnos a procesar su queja. Si necesita ayuda para
completar este formulario, por favor póngase en contacto con el Administrador de Programas de GSMD
llamando al 713-942-0500. El formulario completo deberá ser devuelto a la siguiente dirección: Greater
Southeast Management District, 5445 Almeda, Suite #503, Houston, Texas 77004.
Nombre:
Teléfono:
Dirección residencial:
Teléfono Alternativo:
Ciudad, Estado, y Código Postal:
Persona(s) contra la(s) que se discriminó (si no se trata de la persona que presenta la queja):
Nombre(s):
Dirección residencial, Ciudad, Estado, y Código Postal:
¿Cuál de los siguientes casos describe mejor la razón de la
Fecha del incidente:
presunta discriminación? (Circule una opción)
 Raza
 Color
 Origen nacional (Conocimiento limitado del inglés)
Por favor describa el presunto incidente discriminatorio. Proporcione los nombres y puestos de todos los
empleados de GSMD que estuvieron involucrados, si están disponibles. Explique lo qué fue lo que
sucedió y quién considera que fue responsable. Por favor use el reverso de este formulario si requiere
espacio adicional.
F O R M U L A R I O D E Q U E J A S D E L T Í T U L O VI
El Distrito Administrativo de Greater Southeast
Por favor describa el presunto incidente discriminatorio (continuación)
¿Ha presentado usted una queja ante alguna otra agencia federal, estatal o local?
(Marque con un círculo) Si / No
Si la respuesta es “Si,” indique a continuación la agencia o agencias y la información de
contacto:
Agencia:
Nombre de contacto:
Dirección, Ciudad, Estado, Código postal:
Teléfono:
Agencia:
Nombre de contacto:
Dirección, Ciudad, Estado, Código postal:
Teléfono:
Firma de quien presenta la queja
Fecha
Imprima el nombre de quien presenta la queja
Date Received:
Review By: