Civil Rights Complaint Record
E 1312.30
Civil Rights Complaint Record
Child Nutrition Services
Teaching and Learning Support
801 West 10th Street, Suite 200
P.O. Box 110500
Juneau, Alaska 99811-0500
(907) 465-8708
Name of Sponsor:
Name of Complainant:
Site of Complaint:
Reported by:
Nature of Complaint: (race, color, national origin, age, sex, disability)
Date reported to sponsor:
Date reported to state:
Date reported to FNS:
CNS staff documenting report:
Please fill out this form and send to either of the following agencies:
Program Administrator, Child Nutrition Services
Teaching and Learning Support
Alaska Department of Education and Early Development
801 West 10th Street, Suite 200
Juneau Alaska 99811-0500
Director, USDA, Office of Civil Rights
Room 326-W
Whitten Building
1400 Independence Avenue, SW
Washington, DC 20250-9410
USDA is an equal opportunity provider and employer.