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Fairfield County Transit
Title VI Complaint Form
Section I: Type of Comment
Type of Comment
Compliment
Suggestion
Complaint
Other
ADA Related
Yes
No
Section II: Contact Information
Salutation
Full Name
Rider ID (if applicable)
Street Address
City, State, Zip
Phone
Email
Section III: Comment Details
Date of Occurrence (MM/DD/YYYY)
Time of Occurrence
Route Name/Number
Location of Incident
Employee Name/ID (if known)
Description of Incident
Section IV: Follow Up & Desired Response
Best way to reach you
Phone
Email
Mail
Response format preferred
Telephone
Email
U.S. Mail
