Complaint

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Categories:

Complaint Detail

Where did this happen?

Date:

Approximate Time:

Enter time in 30-minute intervals (e.g. 1:30 PM, 2:00 PM). Enter manually or use drop-down.

Name of TSA employee (if known):

Airline Name:

Flight Number:

Checkpoint/Area of Airport:

Baggage Type

Carry-on

Checked

TSA Notice of Inspection?

Yes

Please provide a description of your inquiry/comment.

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Passenger Information

First Name:

Last Name:

Email:

Confirm email

Phone:

Civil Rights and Liberties Detail

What is your complaint about?

Other:

Where did this happen?

Airline Name:

Flight Number:

Date:

In order for your complaint to be considered complete, you must file within 180 days of the alleged act of discrimination.

Approximate Time:

Enter time in 15-minute increments (e.g. 1:15 PM, 1:30 PM, 1:45 PM). Enter manually or use drop-down.

Please provide a description of the issue.

* Please do not use special characters like @, #, $, %, &, -, ", ', {, (, [ or > .

List any witnesses:

Name of TSA employee (if known):

Are you filing this form for yourself?

Name of individual allegedly subjected to discrimination

Relationship

Contact Information

First Name:

Last Name:

Address:

Street Address

City

State

Zip Code

Phone:

Email:

Confirm email

Preferred Language to Respond

Preferred Time to be contacted

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