Language Access Complaint Elevation Form

1. Adaptive Form Title

3. Name

4. Address

5. City

6. State

7. Zip

9. Home
10. Cell
11. What’s the best time to call you?

12. Email

13. What language do you prefer to use?

14. Do you read and write in this language?
15. Did someone help you fill out this form?
16. Section

17. 2. Which state agency did you seek services from?

18. 3. When did you submit a complaint to the state agency?

19. 4. What problems did you have when trying to access services from the state agency? (Check all that apply)

20. Please describe the problem you experienced

21. 5. What kind of help do you need? (Check all that apply)

22. Please describe the kind of help you need
24. Please describe the details
26. CAPTCHA

• Section

Office of New Americans Language Access Complaint Elevation Form

1. Tell Us About You

Name

Address

City

State

Zip

Phone Numbers:

Home

Cell

What’s the best time to call you?

8AM-12AM

12PM-4PM

Email

What language do you prefer to use?

Do you read and write in this language?

Yes

No

Did someone help you fill out this form?

Yes

No

If yes, please provide their information:

Name

Phone

Email

2. Which state agency did you seek services from?

3. When did you submit a complaint to the state agency?

4. What problems did you have when trying to access services from the state agency? (Check all that apply)

I was not offered an interpreter or language assistance services

I asked for an interpreter but was not provided one

The interpreter did not provide accurate interpretation

I asked for a document to be translated and was denied (please list the document(s) below under “Tell us what happened.”)

The translated document I received was inaccurate (please list the document(s) below under “Tell us what happened.”)

I was not able to access the website due to a language barrier

I was unable to access a video because it did not have captions or subtitles

Other

Please describe the problem you experienced

5. What kind of help do you need? (Check all that apply)

Reading

Writing

Audio

Video

Interpreter

Other

Please describe the kind of help you need

6. Tell us what happened.

Tell us what happened after you submitted a complaint to the agency. For example, include:

• When? (date and time)
• Who was involved?
• What kind of help did they offer?
• What went wrong?

Please describe the details

NOTE: This form is intended to gather information about your complaint. The Office of New Americans will review your complaint. You will be notified when your complaint is resolved. You can submit this form without providing your name and contact information. However, if you choose to remain anonymous, we will not be able to contact you for more details or update you on the resolution of the complaint.

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