Labor & Industries (L&I), Washington State



Civil Rights ProgramPO Box 44001Olympia WA 98504-4001Phone: 855-682-0778Fax: 360-902-4202Email: CivilRights@Lni.Discrimination Complaint InstructionsFor L&I customers claiming discrimination against L&I Employees and L&I Paid ProvidersDiscrimination is against the lawThe Washington State Department of Labor & Industries (L&I) complies with all applicable federal and state laws, rules and regulations, and strives to provide all customers with timely and meaningful access to its programs and services. L&I does not exclude people or treat them differently because of race, color, national origin, language, religion, disability, gender, sex or other protected class.L&I provides free language assistance services to all customers and free aid to people with disabilities while they are receiving services or doing business with L&I, including:Interpreter services with a certified interpreter, in person or over the phone.Qualified sign language interpreters.Translation of L&I documents in your preferred language.Written information in large print, audio, accessible electronic formats, or other formats.This complaint form is for anyone who:Requested — but believes they did NOT receive — services in their preferred language (including sign language services) from any L&I employee, or L&I paid provider,and/orBelieves that an L&I employee or L&I paid provider excluded them or treated them differently because of their race, color, national origin, language, religion, disability, gender, sex or other protected class.Important:Three ways to file a complaint with us: Complete this form and mail it to the address listed at the top of the page.Call us toll-free at 1-855-682-0778.Email us at CivilRights@Lni. and tell us briefly about your complaint.The Civil Rights Program – Promoting Access, Equity, and Respect for all L&I CustomersWe will complete a fair, impartial, and thorough investigation of your civil rights complaint. Our office is independent of other L&I programs and does not represent any party.Don’t want to file your complaint with L&I? You may also file your complaint with:Washington State Office of the Attorney General: 800-551-4636 (atg.).Washington State Human Rights Commission: 800-233-3247 (hum.).US Department of Justice: 800-514-0301 ().US Department of Labor: 202-693-6500 ().Civil Rights ProgramPO Box 44001Olympia WA 98504-4001Phone: 855-682-0778Fax: 360-902-4202Email: CivilRights@Lni.Discrimination ComplaintFor L&I customers claiming discrimination against L&I employees and L&I paid providersIf you need an interpreter or a copy of this form in your preferred language, just ask!Your InformationLanguage Preference (check one) FORMCHECKBOX English FORMCHECKBOX Espa?ol/Spanish FORMCHECKBOX ????/Cambodian FORMCHECKBOX 简体中文/Chinese Simplified FORMCHECKBOX 繁體中文/Chinese Traditional FORMCHECKBOX ???/Korean FORMCHECKBOX Русский/Russian FORMCHECKBOX Soomaali/Somali FORMCHECKBOX Ti?ng Vi?t /Vietnamese FORMCHECKBOX Other:First Name FORMTEXT ?????Last Name FORMTEXT ?????Address FORMTEXT ?????City FORMTEXT ?????State FORMTEXT ?????Zip Code FORMTEXT ?????Country FORMTEXT ?????Email Address FORMTEXT ?????Phone Number FORMTEXT ?????Phone Number of Family or Friend (optional) FORMTEXT ?????If your address or phone number changes after you submit a complaint, please let us know right plaint DetailsType of complaint (check all that apply) FORMCHECKBOX Language Access FORMCHECKBOX Discrimination FORMCHECKBOX Lack of AccommodationWhen did this happen? Use month/day/year formatDescribe your complaint. Attach additional pages if needed. Please write your name on each attached page. FORMTEXT ?????Why do you believe you were treated this way? FORMTEXT ?????Have you filed a complaint about this issue before? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, when and with whom? Use month/day/year format FORMTEXT ?????Who is the complaint about? (if known) Attach additional pages, if needed. Please write your name on each attached pageName the person you believe discriminated against you FORMTEXT ?????Title FORMTEXT ?????Phone number FORMTEXT ?????Name the person you believe discriminated against you FORMTEXT ?????Title FORMTEXT ?????Phone number FORMTEXT ?????Name the person you believe discriminated against you FORMTEXT ?????Title FORMTEXT ?????Phone number FORMTEXT ?????Name of witness to the incident FORMTEXT ?????Phone number FORMTEXT ?????Name of witness to the incident FORMTEXT ?????Phone number FORMTEXT ????? FORMTEXT ?????Signature*Date*Mail completed form to the address listed above or call 855-682-0778 if you have questions about confidentiality, completing, or sending this form to us. ................
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