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2. Town of Castle Rock is committed to providing you with a safe and welcoming community and we want your feedback. Please use this form for suggestions, compliments, and complaints. 

   
   

   You may also call us at 303-660-1374 or mail to: Town of Castle Rock, 100 N. Wilcox St., Castle Rock, CO 80104.

   
   

   Please make sure to provide your contact information in order to receive a response.

6. Section A: Accessible Format Requirements

8. Please check the preferred format for this document*

   1. Large Print
   2. TDD or Relay
   3. Audio Recording
   4. Other (if selected please state what type of formant you need in the box below).
10. Other format

12. Section B: Contact Information

14. First and Last Name*
15. Phone number (including area code)*
17. Address*
19. City*
20. State*
21. Zip code*
23. Email address*
25. Are you filing this complaint on your own behalf? *

    1. Yes
    2. No
27. If no, please provide the name and relationship of the person for whom you are complaining and why you are completing the form on their behalf in the box below.*
28. Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.*

    1. Yes
    2. No

30. Section C: Type of Comment

32. What type of comment are you providing? Please check which category best applies.*

    1. Complaint
    2. Suggestion
    3. Compliment
    4. Other
33. Which of the following describes the nature of the comment? Please check one or more of the check boxes.*

    1. Race
    2. Color
    3. National Origin
    4. Religion
    5. Age

    1. Sex
    2. Service
    3. Income Status
    4. Limited English Proficient (L.E.P.)
    5. Americans with Disability Act (A.D.A)

35. Section D: Comment Details

37. What was the date and time of the occurrence?*
    What was the date and time of the occurrence?

    What was the date and time of the occurrence?
39. What is the name or identification of the employee or employees involved?*
40. What is the name or identification of others involved, if applicable?*
42. Where was the location of the occurrence?*
43. Please add any additional descriptive details about the incident. *
45. In the box below, please explain as clearly as possible what happened and why you believe you were discriminated against.*

47. Section E: Follow-up

49. May we contact you if we need more details or information?*

    1. Yes
    2. No
50. If yes, how would you best liked to be reached? Please select your preferred form of contact below.

    1. Phone
    2. Email
    3. Mail
53. If you would prefer to be contacted by phone, please list the best day and time to reach you.

55. Section F: Desired Outcome

57. Please list below, what steps you would like taken to address the conflict or problem.*
59. If applicable, please list below all additional agencies you have filed this complaint with such as Federal, State, Local agencies, or with any Federal or State Court. Please include the contact information to where the complaint was sent.

61. Section G: Signature

63. Please attach any documents you have which support the allegation. Then date and sign this form and submit it to the Town of Castle Rock.
65. Signature*

    Typing your name above constitutes a legal signature whereby you are confirming the information provided in this form is true and correct to the best of your knowledge.

66. Date*
Leave This Blank:


68. 1. Receive an email copy of this form.
69. Email address

    This field is not part of the form submission.

70. Submit

* indicates a required field