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Complainant Information

Complainant Information
The Town of Carrboro is committed to providing equal access to Town services to individuals with limited English proficiency (LEP).
Complete this form to file a language access complaint or to allege noncompliance with the Town of Carrboro Language Access Plan. All complaints should be submitted within 30 days after the alleged violation. The Town will conduct a thorough investigation of your concerns and attempt to resolve the issue within 30 days of receipt of your complaint.
All general questions or concerns about the Town’s Language Access Plan should be sent to the Communication & Engagement Department at communications@carrbornc.gov
Complainant Information
First Name*
Last Name*
Address*
Address
City*
State*
Zip*
Phone Number*
Email Address*
How do you prefer we contact you? (Choose one)*
What language do you prefer to communicate in?*
Do you require languge interpretation/translation? If so, what language?*
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Date of Incident:*
Date of Incident:
Location of incident:*
Nature of complaint:*
1. Failure to prominently display language access information in waiting/receptionareas.
2. Failure or refusal to identify your langugae needs.
3. Failure to provide interpretaiton, translation or other language service.
4. Discrimination based on limited English proficiency.
5. Other violation of the Language Access Plan policy. Explain:
Other violation of the Language Access Plan policy: Explain:
Did staff offer interpretation and/or translation services?*
1. Yes
2. No
Did you alert staff of your language preference or the need for language services?*
1. Yes
2. No
Please describe what happened*
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For Town Staff Filing Verbal Complaints Only
If you are filling out this form on behalf of an LEP individual, please provide the following information:
Date Complaint Received
Date Complaint Received
Staff Name:
Department:
Staff Phone Number:
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Complainant Signature*
Date*
Date
By submitting this form, you acknowledge that submission does not constitued filing of charges and certify that all information is accurate to the best of your knowledge*
1. Yes
1. Receive an email copy of this form
Email Address
This field is not part of the form submission

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