Complaint

What is your complaint about? *

Other: *

Where did this happen? *

Airline & Flight Number:

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

Date: *

Month

Day

Year

Approximate Time:

Hour

:

Minute

am

pm

Please provide a description of the issue. *

* We will remove the following special characters like @, #, $, %, &, -, ", {, (, [ or > . Please do not include them in your submission.

List any witnesses:

Name of TSA employee (if known):

Are you filing this form for yourself? *

Yes

No

Name of individual allegedly subjected to discrimination *

Relationship *

Authorized consent *

Preferred Language to Respond

Preferred Time to be contacted

Consent *

I will cooperate with TSA's complaint resolution activities undertaken on my behalf. I understand that my failure to cooperate with TSA may result in the closure of my complaint. I understand that the TSA may share the information I have provided as needed to resolve this complaint.

Transportation Security Administration

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