Iowa Department of Natural Resources              Title VI/Discrimination Complaint (non-employee)
Items with asterisk (*) are required. Failure to complete these items may result in processing delay or rejection.

Submissions, including attachments, are unable to be returned. You may wish to retain a copy of your submission for your records.

If you have questions or wish to attach additional documents, contact:
Iowa Department of Natural Resources
c/o Rachel Zander or Emily Cohen
Nondiscrimination Coordinators
Wallace State Office Bldg.
502 E. 9th St.
Des Moines, IA 50319
civilrights@dnr.iowa.gov 
Sign in to Google to save your progress. Learn more
Email *
Name *
Mailing Address *
Residential Address (if different from Mailing Address)
Phone number (recommended)
Email address (recommended)
 What entity does this complaint concern? Please be as specific as possible in identifying the agency or organization that allegedly committed the discriminatory act described herein. You may list multiple entities. If you are unsure, provide as much identifying information as you are able. Do not leave blank. Department staff will follow up if additional identifying information is needed. *
What prompted this complaint? Please describe in as much detail as possible, including relevant dates, why you feel the entity listed above discriminated against you or others on the basis of race, color, national origin, English-language proficiency, sex (including sexual orientation and gender identity), disability, age; and/or why you feel the entity listed above engaged in prohibited intimidation or retaliation. You may attach additional pages, including photographs or copies of documents, if desired. *
Is this complaint being filed within 180 days of the date of the last alleged act of discrimination? *
If you checked “No” above, state what you believe to be good cause for extending the 180-day deadline for filing. If you checked "Yes" write "N/A" below. *
Please provide the names, addresses, and phone numbers of any persons who may have knowledge of the events giving rise to this complaint.
Please provide any additional information you believe may assist Department staff in timely reviewing and investigating this complaint.
Type your name and today's date below to electronically sign this complaint. *
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of State of Iowa. Report Abuse
Google Forms