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 class="formidable" id="formidable_73408"> <div id="formidable_msd_language_access_complaint_73408" class=""> <div class="alert alert-danger hide" data-formidable-message> </div> <form action="https://www.sos.ca.gov/administration/language-access-complaint-form/submit/73408" method="post" class="needs-validation" novalidate enctype="multipart/form-data"> <input type="hidden" id="formID" name="formID" value="25" /> <input type="hidden" id="ccm_token" name="ccm_token" value="1739811793:6ac3aeef30bba406fe3b5698e2ccc8a3" /> <input type="hidden" id="bID" name="bID" value="73408" /> <input type="hidden" id="cID" name="cID" value="14995" /> <div class="row "> <div class="col-12 col-sm-12 "> <div class="form-group" data-formidable-type="code" data-formidable-handle="section_a_customer_information"> <h2>Section A - Customer Information</h2> </div> <div class="form-group" data-formidable-type="text" data-formidable-handle="your_name"> <label for="your_name" class="form-label">Your Name:</label> <span class="small text-danger">*</span> <input type="text" id="your_name" name="your_name" value="" data-element-handle="your_name" class="form-control ccm-input-text" /> </div> <div class="form-group" data-formidable-type="options" data-formidable-handle="how_should_we_contact_you_select_all_that_apply"> <label for="how_should_we_contact_you_select_all_that_apply" class="form-label">How should we contact you (select all that apply)?</label> <span class="small text-danger">*</span> <div data-checkbox-list class=""><div class="form-check custom-control custom-checkbox"><input type="checkbox" id="how_should_we_contact_you_select_all_that_apply_email" name="how_should_we_contact_you_select_all_that_apply[]" class="form-check-input custom-control-input form-check-input" data-element-handle="how_should_we_contact_you_select_all_that_apply" value="email" /><label for="how_should_we_contact_you_select_all_that_apply_email" class="form-check-label custom-control-label">Email</label></div><div class="form-check custom-control custom-checkbox"><input type="checkbox" id="how_should_we_contact_you_select_all_that_apply_phone" name="how_should_we_contact_you_select_all_that_apply[]" class="form-check-input custom-control-input form-check-input" data-element-handle="how_should_we_contact_you_select_all_that_apply" value="phone" /><label for="how_should_we_contact_you_select_all_that_apply_phone" class="form-check-label custom-control-label">Phone</label></div><div class="form-check custom-control custom-checkbox"><input type="checkbox" id="how_should_we_contact_you_select_all_that_apply_mail" name="how_should_we_contact_you_select_all_that_apply[]" class="form-check-input custom-control-input form-check-input" data-element-handle="how_should_we_contact_you_select_all_that_apply" value="mail" /><label for="how_should_we_contact_you_select_all_that_apply_mail" class="form-check-label custom-control-label">Mail</label></div></div> </div> <div class="form-group" data-formidable-type="text" data-formidable-handle="your_street_address"> <label for="your_street_address" class="form-label">Your Street Address:</label> <input type="text" id="your_street_address" name="your_street_address" value="" data-element-handle="your_street_address" class="form-control ccm-input-text" /> </div> <div class="form-group" data-formidable-type="text" data-formidable-handle="your_city"> <label for="your_city" class="form-label">Your City:</label> <input type="text" id="your_city" name="your_city" value="" data-element-handle="your_city" class="form-control ccm-input-text" /> </div> <div class="form-group" data-formidable-type="text" data-formidable-handle="your_state"> <label for="your_state" class="form-label">Your State:</label> <input type="text" id="your_state" name="your_state" value="" data-element-handle="your_state" class="form-control ccm-input-text" /> </div> <div class="form-group" data-formidable-type="text" data-formidable-handle="your_zip_code"> <label for="your_zip_code" class="form-label">Your Zip Code:</label> <input type="text" id="your_zip_code" name="your_zip_code" value="" data-element-handle="your_zip_code" class="form-control ccm-input-text" /> </div> <div class="form-group" data-formidable-type="text" data-formidable-handle="language_spoken"> <label for="language_spoken" class="form-label">Language Spoken:</label> <input type="text" id="language_spoken" name="language_spoken" value="" data-element-handle="language_spoken" class="form-control ccm-input-text" /> </div> <div class="form-group" data-formidable-type="text" data-formidable-handle="your_phone_number"> <label for="your_phone_number" class="form-label">Your Phone Number:</label> <input type="text" id="your_phone_number" name="your_phone_number" value="" data-element-handle="your_phone_number" class="form-control ccm-input-text" /> </div> <div class="form-group" data-formidable-type="email" data-formidable-handle="your_email_address"> <label for="your_email_address" class="form-label">Your Email Address:</label> <input type="email" id="your_email_address" name="your_email_address" value="" data-element-handle="your_email_address" class="form-control ccm-input-email" /> </div> </div> </div> <div class="row "> <div class="col-12 col-sm-12 "> <div class="form-group" data-formidable-type="code" data-formidable-handle="section_b_complaint_details"> <h2>Section B - Complaint Details</h2> </div> <div class="form-group" data-formidable-type="text" data-formidable-handle="date_of_incident"> <label for="date_of_incident" class="form-label">Date of Incident:</label> <input type="text" id="date_of_incident" name="date_of_incident" value="" data-element-handle="date_of_incident" class="form-control ccm-input-text" /> </div> <div class="form-group" data-formidable-type="text" data-formidable-handle="location_of_office"> <label for="location_of_office" class="form-label">Location of Office:</label> <input type="text" id="location_of_office" name="location_of_office" value="" data-element-handle="location_of_office" class="form-control ccm-input-text" /> </div> <div class="form-group" data-formidable-type="text" data-formidable-handle="division_or_unit"> <label for="division_or_unit" class="form-label">Division or Unit:</label> <input type="text" id="division_or_unit" name="division_or_unit" value="" data-element-handle="division_or_unit" class="form-control ccm-input-text" /> </div> <div class="form-group" data-formidable-type="options" data-formidable-handle="language_access_issues_check_all_that_apply"> <label for="language_access_issues_check_all_that_apply" class="form-label">Language Access Issues (check all that apply):</label> <div data-checkbox-list class=""><div class="form-check custom-control custom-checkbox"><input type="checkbox" id="language_access_issues_check_all_that_apply_lack_of_assistance_by_agency_staff_in_non_english_language" name="language_access_issues_check_all_that_apply[]" class="form-check-input custom-control-input form-check-input" data-element-handle="language_access_issues_check_all_that_apply" value="Lack of assistance by agency staff in non-English language" /><label for="language_access_issues_check_all_that_apply_lack_of_assistance_by_agency_staff_in_non_english_language" class="form-check-label custom-control-label">Lack of assistance by agency staff in non-English language</label></div><div class="form-check custom-control custom-checkbox"><input type="checkbox" id="language_access_issues_check_all_that_apply_lack_of_translated_materials_in_non_english_language" name="language_access_issues_check_all_that_apply[]" class="form-check-input custom-control-input form-check-input" data-element-handle="language_access_issues_check_all_that_apply" value="Lack of translated materials in non-English language" /><label for="language_access_issues_check_all_that_apply_lack_of_translated_materials_in_non_english_language" class="form-check-label custom-control-label">Lack of translated materials in non-English language</label></div><div class="form-check custom-control custom-checkbox"><input type="checkbox" id="language_access_issues_check_all_that_apply_interpreter_available_was_not_skilledknowledgeable" name="language_access_issues_check_all_that_apply[]" class="form-check-input custom-control-input form-check-input" data-element-handle="language_access_issues_check_all_that_apply" value="Interpreter available was not skilled/knowledgeable" /><label for="language_access_issues_check_all_that_apply_interpreter_available_was_not_skilledknowledgeable" class="form-check-label custom-control-label">Interpreter available was not skilled/knowledgeable</label></div><div class="form-check custom-control custom-checkbox"><input type="checkbox" id="language_access_issues_check_all_that_apply_translations_were_not_accurate" name="language_access_issues_check_all_that_apply[]" class="form-check-input custom-control-input form-check-input" data-element-handle="language_access_issues_check_all_that_apply" value="Translations were not accurate" /><label for="language_access_issues_check_all_that_apply_translations_were_not_accurate" class="form-check-label custom-control-label">Translations were not accurate</label></div><div class="form-check custom-control custom-checkbox"><input type="checkbox" id="language_access_issues_check_all_that_apply_other" name="language_access_issues_check_all_that_apply[]" class="form-check-input custom-control-input form-check-input" data-element-handle="language_access_issues_check_all_that_apply" value="Other" /><label for="language_access_issues_check_all_that_apply_other" class="form-check-label custom-control-label">Other</label></div></div> </div> <div class="form-group" data-formidable-type="options" data-formidable-handle="what_language_did_you_need_assistance_with"> <label for="what_language_did_you_need_assistance_with" class="form-label">What language did you need assistance with?</label> <div data-checkbox-list class=""><div class="form-check custom-control custom-checkbox"><input type="checkbox" id="what_language_did_you_need_assistance_with_cantonese" name="what_language_did_you_need_assistance_with[]" class="form-check-input custom-control-input form-check-input" data-element-handle="what_language_did_you_need_assistance_with" value="Cantonese" /><label for="what_language_did_you_need_assistance_with_cantonese" class="form-check-label custom-control-label">Cantonese</label></div><div class="form-check custom-control custom-checkbox"><input type="checkbox" id="what_language_did_you_need_assistance_with_hmong" name="what_language_did_you_need_assistance_with[]" class="form-check-input custom-control-input form-check-input" data-element-handle="what_language_did_you_need_assistance_with" value="Hmong" /><label for="what_language_did_you_need_assistance_with_hmong" class="form-check-label custom-control-label">Hmong</label></div><div class="form-check custom-control custom-checkbox"><input type="checkbox" id="what_language_did_you_need_assistance_with_mandarin" name="what_language_did_you_need_assistance_with[]" class="form-check-input custom-control-input form-check-input" data-element-handle="what_language_did_you_need_assistance_with" value="Mandarin" /><label for="what_language_did_you_need_assistance_with_mandarin" class="form-check-label custom-control-label">Mandarin</label></div><div class="form-check custom-control custom-checkbox"><input type="checkbox" id="what_language_did_you_need_assistance_with_russian" name="what_language_did_you_need_assistance_with[]" class="form-check-input custom-control-input form-check-input" data-element-handle="what_language_did_you_need_assistance_with" value="Russian" /><label for="what_language_did_you_need_assistance_with_russian" class="form-check-label custom-control-label">Russian</label></div><div class="form-check custom-control custom-checkbox"><input type="checkbox" id="what_language_did_you_need_assistance_with_spanish" name="what_language_did_you_need_assistance_with[]" class="form-check-input custom-control-input form-check-input" data-element-handle="what_language_did_you_need_assistance_with" value="Spanish" /><label for="what_language_did_you_need_assistance_with_spanish" class="form-check-label custom-control-label">Spanish</label></div><div class="form-check custom-control custom-checkbox"><input type="checkbox" id="what_language_did_you_need_assistance_with_tagalog" name="what_language_did_you_need_assistance_with[]" class="form-check-input custom-control-input form-check-input" data-element-handle="what_language_did_you_need_assistance_with" value="Tagalog" /><label for="what_language_did_you_need_assistance_with_tagalog" class="form-check-label custom-control-label">Tagalog</label></div><div class="form-check custom-control custom-checkbox"><input type="checkbox" id="what_language_did_you_need_assistance_with_other" name="what_language_did_you_need_assistance_with[]" class="form-check-input custom-control-input form-check-input" data-element-handle="what_language_did_you_need_assistance_with" value="Other" /><label for="what_language_did_you_need_assistance_with_other" class="form-check-label custom-control-label">Other</label></div></div> </div> <div class="form-group" data-formidable-type="textarea" data-formidable-handle="brief_description_of_complaint"> <label for="brief_description_of_complaint" class="form-label">Brief Description of Complaint:</label> <textarea id="brief_description_of_complaint" name="brief_description_of_complaint" data-element-handle="brief_description_of_complaint" class="form-control"></textarea> </div> <div class="form-group" data-formidable-type="date" data-formidable-handle="date_of_incident_1"> <label for="date_of_incident_1" class="form-label">Date of Incident:</label> <input type="date" id="date_of_incident_1_316" name="date_of_incident_1" value="" data-element-handle="date_of_incident_1" data-date="" data-date-format="YYYY/MM/DD" class="form-control ccm-input-text" /> </div> </div> </div> <div class="row "> <div class="col-12 col-sm-12 "> <div class="form-group" data-formidable-type="code" data-formidable-handle="section_c_form_assistance"> <h2>Section C - Form Assistance</h2> </div> <div class="form-group" data-formidable-type="options" data-formidable-handle="did_someone_assist_you_in_completing_this_form"> <label for="did_someone_assist_you_in_completing_this_form" class="form-label">Did someone assist you in completing this form?</label> <div data-radio-list class=""><div class="form-check custom-control custom-radio"><input type="radio" id="did_someone_assist_you_in_completing_this_form_yes" name="did_someone_assist_you_in_completing_this_form[]" value="yes" class="form-check-input custom-control-input form-check-input" data-element-handle="did_someone_assist_you_in_completing_this_form" /><label for="did_someone_assist_you_in_completing_this_form_yes" class="form-check-label custom-control-label">Yes</label></div><div class="form-check custom-control custom-radio"><input type="radio" id="did_someone_assist_you_in_completing_this_form_no" name="did_someone_assist_you_in_completing_this_form[]" value="no" class="form-check-input custom-control-input form-check-input" data-element-handle="did_someone_assist_you_in_completing_this_form" /><label for="did_someone_assist_you_in_completing_this_form_no" class="form-check-label custom-control-label">No</label></div></div> </div> <div class="form-group" data-formidable-type="name" data-formidable-handle="name_of_assistant"> <label for="name_of_assistant" class="form-label">Name of Assistant:</label> <div class="row"><div class="col"><input type="text" id="name_of_assistant[firstname]" name="name_of_assistant[firstname]" value="" data-element-handle="name_of_assistant" class="firstname form-control form-control ccm-input-text" placeholder="First Name" /></div> <div class="col"><input type="text" id="name_of_assistant[lastname]" name="name_of_assistant[lastname]" value="" data-element-handle="name_of_assistant" class="lastname form-control form-control ccm-input-text" placeholder="Last Name" /></div></div> </div> <div class="form-group" data-formidable-type="text" data-formidable-handle="organization"> <label for="organization" class="form-label">Organization</label> <input type="text" id="organization" name="organization" value="" data-element-handle="organization" class="form-control ccm-input-text" /> </div> <div class="form-group" data-formidable-type="text" data-formidable-handle="assistants_phone_number_including_area_code"> <label for="assistants_phone_number_including_area_code" class="form-label">Assistant's Phone Number (including area code):</label> <input type="text" id="assistants_phone_number_including_area_code" name="assistants_phone_number_including_area_code" value="" data-element-handle="assistants_phone_number_including_area_code" class="form-control ccm-input-text" /> </div> <div class="form-group" data-formidable-type="email" data-formidable-handle="assistants_email"> <label for="assistants_email" class="form-label">Assistant's Email:</label> <input type="email" id="assistants_email" name="assistants_email" value="" data-element-handle="assistants_email" class="form-control ccm-input-email" /> </div> </div> </div> <div class="row mt-2"> <div class="col-12"> <button type="submit" class="btn btn-primary"> Submit <i class="fas fa-spinner fa-spin"></i> </button> </div> </div> </form> </div> <script> var formidable_msd_language_access_complaint_73408; $(function() { var settings = { locale: 'en_US', errors: 'element', errorsAdditionalClass: '', successAdditionalClass: '', successHideForm: true, scrollToTop: true, scrollOffset: 0, scrollTime: 200, dependencies: {"selectors":[],"rules":[]}, onloadCallback: '', errorsCallback: '', successCallback: '', }; formidable_msd_language_access_complaint_73408 = $('[id="formidable_msd_language_access_complaint_73408"]').formidable(settings); }); </script> </div> </div></div></div> </div> </main> <div id="contact-actions" role="complementary"> <div class="container"> <div class="row"> <div class="col-xs-12"> <div id="contact-actions-outer"> <div id="contact-actions-inner"> <div id="contact-actions-call"> <i aria-hidden="true"><img src="https://www.sos.ca.gov/application/files/3815/9681/5355/icon-call.svg" alt="Call Us"></i> <h2>Call Us</h2> <a href="tel:9166536814">(916) 653-6814</a> </div> <div id="contact-actions-update"> <i aria-hidden="true"><img src="https://www.sos.ca.gov/application/files/5615/9681/5355/icon-updates.svg" alt="Receive 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Language Access Complaint Form :: California Secretary of State