CitiBus Complaint/Incident Form

 Step 1 of 1

* Denotes a required field

Complainant Contact Information

*
*
*
*
*
Phone # (Enter 999-999-9999, if N/A)*
-- ext
*
Did someone complete or assist with completion of this form?*
*

Information about the incident/complaint.

Does your complaint involved alleged discrimination? (Race, Color, National Origin, Disability, Religion, Gender)?*
If Yes, what is the alleged discrimination? If no, use N/A from the dropdown. If the category of discrimination is not listed, select other.*
Date and Time of Incident*
 ,   :  
*
Please describe the alleged incident/complaint. Explain what happened. Provide the names and title of all Davenport employees involved, if available. Provide the names of witnesses, if available.
*
 
Have you filed a complaint with any other federal, state, or local agencies?*
*

By clicking submit below, you agree that the information provided in this complaint is true to the best of your knowledge, information, and belief.