Language Access Complaint Form

Information

Required fields are marked with an asterisk.(*)

Complete this form to report an issue related to the availability and quality of language services provided by the Department of State. The Department’s Language Access Coordinator reviews complaints for appropriate resolution. The Department of State will acknowledge receipt of a complaint within five (5) days and respond to the complaint within a reasonable amount of time.

First Name

Last Name

Phone Number

What language do you speak?

What language service do you need?

If “other” please describe.

What Department of State service do you need?

If “other” please describe.

Date of Incident MM/DD/YYYY

Please describe your complaint

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