Language Access Complaint Form :: California Secretary of State

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office to provide effective communication to all people utilizing public services.聽 If you feel the Secretary of State's office was unable to serve you because of a language barrier (limited-English proficiency) or other communication differences, the Secretary of State's office may be able to provide additional communication assistance that will assist you with the information or services you have requested.</p> <p>Please use this form to report any language access complaint you have encountered at the Secretary of State's office.聽</p> <p>If you prefer, you can <a href="https://admin.cdn.sos.ca.gov/msd/language-access-complaint-form-rev201507.pdf">download the form and complete it offline <span class="fileTp">(PDF)</span></a>. 聽Once completed, mail the form and any supporting documentation to聽<strong>Secretary of State, Human Resources office, 1500 11<sup>th</sup>聽Street Room 475, Sacramento, CA 聽95814, Attention: Equal Employment Opportunity Officer</strong>聽or fax the form to (916) 653-8024.</p> </div></div></div> <div class="container"><div class="row"><div class="col-sm-12"> <p><span class="rdBld">All fields marked with an asterisk (*) are required.</span></p> </div></div></div> <div class="container"><div class="row"><div class="col-sm-12"> <div id="formidable_container_28" class="formidable "> <div id="formidable_message_28" class="formidable_message"> </div> <form id="ff_28" name="formidable_form" method="post" class="" action="https://www.sos.ca.gov/formidable/dialog/formidable"> <input type="hidden" name="formID" id="formID" value="28"> <input type="hidden" name="cID" id="cID" value="14995"> <input type="hidden" name="bID" id="bID" value="30850"> <input type="hidden" name="resolution" id="resolution" value=""> <input type="hidden" name="ccm_token" id="ccm_token" value="1732693599:9bbe49c725439c90c785ae7a041d878b"> <input type="hidden" name="locale" id="locale" value="en_US"> <input type="hidden" name="step" id="step" value="0"> <div class="formidable_column width-12 last"> <div class="formidable_row " > <div class="element section-a-customer-information-330"> <div class="label-hidden"></div> <div class="input" style="margin-left:0;"> <h2>Section A - Customer Information</h2> </div> </div> <div class="element your-name-331"> <label for="your-name-331"> Your Name: <span class="required">*</span> </label> <div class="input" > <input type="text" id="your-name-331" name="your-name-331" value="" class="form-control ccm-input-text" /> </div> </div> <div class="element how-should-we-contact-you-select-all-that-apply-354"> <label for="how-should-we-contact-you-select-all-that-apply-354"> How should we contact you (select all that apply)? <span class="required">*</span> </label> <div class="input" > </div> </div> <div class="element your-street-address-332"> <label for="your-street-address-332"> Your Street Address: </label> <div class="input" > <input type="text" id="your-street-address-332" name="your-street-address-332" value="" class="form-control ccm-input-text" /> </div> </div> <div class="element your-city-333"> <label for="your-city-333"> Your City: </label> <div class="input" > <input type="text" id="your-city-333" name="your-city-333" value="" class="form-control ccm-input-text" /> </div> </div> <div class="element your-state-352"> <label for="your-state-352"> Your State: </label> <div class="input" > <input type="text" id="your-state-352" name="your-state-352" value="" class="form-control ccm-input-text" /> <div class="help-block"> <div id="your-state-352_counter" class="counter" type="chars" min="0" max="20"> You have <span id="your-state-352_count">20</span> characters left. </div> </div> </div> </div> <div class="element your-zip-code-335"> <label for="your-zip-code-335"> Your Zip Code: </label> <div class="input" > <input type="text" id="your-zip-code-335" name="your-zip-code-335" value="" class="form-control ccm-input-text" /> <div class="help-block"> <div id="your-zip-code-335_counter" class="counter" type="chars" min="0" max="15"> You have <span id="your-zip-code-335_count">15</span> characters left. </div> </div> </div> </div> <div class="element language-spoken-336"> <label for="language-spoken-336"> Language Spoken: </label> <div class="input" > <input type="text" id="language-spoken-336" name="language-spoken-336" value="" title="What language do you speak?" data-toggle="tooltip" class="form-control ccm-input-text" /> <div class="help-block"> <div id="language-spoken-336_counter" class="counter" type="words" min="0" max="5"> You have <span id="language-spoken-336_count">5</span> words left. </div> </div> </div> <div class="qtip" id="tooltip_336"> What language do you speak? </div> </div> <div class="element your-phone-number-337"> <label for="your-phone-number-337"> Your Phone Number: </label> <div class="input" > <input type="text" id="your-phone-number-337" name="your-phone-number-337" value="" title="Enter your phone number including your area code (ex., (999) 333-3333.)" data-toggle="tooltip" class="form-control ccm-input-text" /> </div> <div class="qtip" id="tooltip_337"> Enter your phone number including your area code (ex., (999) 333-3333.) </div> </div> <div class="element your-email-address-338"> <label for="your-email-address-338"> Your Email Address: </label> <div class="input" > <input type="email" id="your-email-address-338" name="your-email-address-338" value="" class="form-control ccm-input-email" /> </div> <div class="clear"></div> <label for="your-email-address-338"> Confirm Your Email Address: </label> <div class="input"> <input type="email" id="your-email-address-338_confirm" name="your-email-address-338_confirm" value="" class="emailaddress_confirm form-control ccm-input-email" /> </div> </div> </div> </div> <div class="formidable_column width-12 last"> <div class="formidable_row " > <div class="element section-b-complaint-details-339"> <div class="label-hidden"></div> <div class="input" style="margin-left:0;"> <h2>Section B - Complaint Details</h2> </div> </div> <div class="element date-of-incident-340"> <label for="date-of-incident-340"> Date of Incident: </label> <div class="input" > <input type="text" id="date-of-incident-340" name="date-of-incident-340" value="" class="form-control ccm-input-text" /> </div> </div> <div class="element location-of-office-341"> <label for="location-of-office-341"> Location of Office: </label> <div class="input" > <input type="text" id="location-of-office-341" name="location-of-office-341" value="" title="Which Secretary of State office were you at when this happened?" data-toggle="tooltip" class="form-control ccm-input-text" /> <div class="help-block"> <div id="location-of-office-341_counter" class="counter" type="words" min="0" max="100"> You have <span id="location-of-office-341_count">100</span> words left. </div> </div> </div> <div class="qtip" id="tooltip_341"> Which Secretary of State office were you at when this happened? </div> </div> <div class="element division-or-unit-342"> <label for="division-or-unit-342"> Division or Unit: </label> <div class="input" > <input type="text" id="division-or-unit-342" name="division-or-unit-342" value="" class="form-control ccm-input-text" /> <div class="help-block"> <div id="division-or-unit-342_counter" class="counter" type="words" min="0" max="20"> You have <span id="division-or-unit-342_count">20</span> words left. </div> </div> </div> </div> <div class="element language-access-issues-check-all-that-apply-343"> <label for="language-access-issues-check-all-that-apply-343"> Language Access Issues (check all that apply): </label> <div class="input" > <div class="checkbox w100"><label for="language-access-issues-check-all-that-apply-343_other"><input type="checkbox" name="language-access-issues-check-all-that-apply-343[]" id="language-access-issues-check-all-that-apply-343_other" value="option_other" > Other (explain)</label></div> </div> <div class="label-hidden"></div> <div class="input option_other"> <textarea id="language-access-issues-check-all-that-apply-343_other" name="language-access-issues-check-all-that-apply-343_other" class="form-control"></textarea> </div> </div> <div class="element what-language-did-you-need-assistance-with-344"> <label for="what-language-did-you-need-assistance-with-344"> What language did you need assistance with? </label> <div class="input" > <div class="checkbox w100"><label for="what-language-did-you-need-assistance-with-344_other"><input type="checkbox" name="what-language-did-you-need-assistance-with-344[]" id="what-language-did-you-need-assistance-with-344_other" value="option_other" > Other (please explain)</label></div> </div> <div class="label-hidden"></div> <div class="input option_other"> <textarea id="what-language-did-you-need-assistance-with-344_other" name="what-language-did-you-need-assistance-with-344_other" class="form-control"></textarea> </div> </div> <div class="element brief-description-of-complaint-355"> <label for="brief-description-of-complaint-355"> Brief Description of Complaint: </label> <div class="input" > <textarea id="brief-description-of-complaint-355" name="brief-description-of-complaint-355" class="form-control"></textarea> <div class="help-block"> <div id="brief-description-of-complaint-355_counter" class="counter" type="words" min="0" max="1000"> You have <span id="brief-description-of-complaint-355_count">1000</span> words left. </div> </div> </div> </div> <div class="element date-of-incident-357"> <label for="date-of-incident-357"> Date of Incident: </label> <div class="input" > <select name="date-of-incident-357[month]" id="date-of-incident-357_month" class=" form-control counter_disabled month"><option value="">month</option><option value="01">01</option><option value="02">02</option><option value="03">03</option><option value="04">04</option><option value="05">05</option><option value="06">06</option><option value="07">07</option><option value="08">08</option><option value="09">09</option><option value="10">10</option><option value="11">11</option><option value="12">12</option></select> / <select name="date-of-incident-357[day]" id="date-of-incident-357_day" class=" form-control counter_disabled day"><option value="">day</option><option value="01">01</option><option value="02">02</option><option value="03">03</option><option value="04">04</option><option value="05">05</option><option value="06">06</option><option value="07">07</option><option value="08">08</option><option value="09">09</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option></select> / <select name="date-of-incident-357[year]" id="date-of-incident-357_year" class=" form-control counter_disabled year"><option value="">year</option><option value="2034">2034</option><option value="2033">2033</option><option value="2032">2032</option><option value="2031">2031</option><option value="2030">2030</option><option value="2029">2029</option><option value="2028">2028</option><option value="2027">2027</option><option value="2026">2026</option><option value="2025">2025</option><option value="2024">2024</option><option value="2023">2023</option><option value="2022">2022</option><option value="2021">2021</option><option value="2020">2020</option><option value="2019">2019</option><option value="2018">2018</option><option value="2017">2017</option><option value="2016">2016</option><option value="2015">2015</option><option value="2014">2014</option><option value="2013">2013</option><option value="2012">2012</option><option value="2011">2011</option><option value="2010">2010</option><option value="2009">2009</option><option value="2008">2008</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option></select> </div> </div> </div> </div> <div class="formidable_column width-12 last"> <div class="formidable_row " > <div class="element section-c-form-assistance-346"> <div class="label-hidden"></div> <div class="input" style="margin-left:0;"> <h2>Section C - Form Assistance</h2> </div> </div> <div class="element did-someone-assist-you-in-completing-this-form-347"> <label for="did-someone-assist-you-in-completing-this-form-347"> Did someone assist you in completing this form? </label> <div class="input" > <div></div> </div> </div> <div class="element name-of-assistant-348"> <label for="name-of-assistant-348"> Name of Assistant: </label> <div class="input" > <input type="text" id="name-of-assistant-348[firstname]" name="name-of-assistant-348[firstname]" value="" class="firstname form-control ccm-input-text" placeholder="Firstname" /> <input type="text" id="name-of-assistant-348[lastname]" name="name-of-assistant-348[lastname]" value="" class="lastname form-control ccm-input-text" placeholder="Lastname" /> </div> </div> <div class="element organization-356"> <label for="organization-356"> Organization </label> <div class="input" > <input type="text" id="organization-356" name="organization-356" value="" class="form-control ccm-input-text" /> <div class="help-block"> <div 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