Fill - Free fillable Baton Rouge College OCR DISCRIMINATION COMPLAINT FORM PDF form

Our Mission is to ensure equal access to education and to promote educational excellence throughout the Nation.

United States Department of Education

Office for Civil Rights

DISCRIMINATION COMPLAINT FORM

You do not have to use this form to file a complaint with the U.S. Department of

Education’s Office for Civil Rights (OCR). You may send OCR a letter or e-mail instead

of this form, but the letter or e-mail must include the information in items one

through nine and item fourteen of this form. If you decide to use this form, please

type or print all information and use additional pages if more space is needed. An on-

line version of this form, which can be submitted electronically, can be found at:

http://www.ed.gov/about/offices/list/ocr/complaintintro.html

Before completing this form please read all information contained in the enclosed packet

including: Information About OCR’s Complaint Resolution Procedures, Notice of Uses of

Personal Information and the Consent Form.

1. Name of person filing this complaint:

Last Name:____________________ First Name:____________________ Middle Name:___________________

Address: _____________________________________________________________________________________________

City:_______________________________________________ State:_______________ Zip Code:_________________

Home Telephone:______________________________ Work Telephone:______________________________

E-mail Address: ____________________________________________________________________________________

2. Name of person discriminated against (if other than person filing). If the perso

iscriminated against is age 18 or older, we will need that person’s signature on this

complaint form and the consent/release form before we can proceed with th

mplaint. If the person is a minor, and you do not have the legal authority to file a

complaint on the student’s behalf, the signature of the child’s parent or legal

guardian is required.

Last Name:____________________ First Name:____________________ Middle Name:___________________

Address: _____________________________________________________________________________________________

City:_______________________________________________ State:_______________ Zip Code:_________________

Home Telephone:______________________________ Work Telephone:______________________________

E-mail Address: ____________________________________________________________________________________

Page 2 of 12 – U.S. Department of Education, Office for Civil Rights Discrimination

Complaint Form, Consent Form, and Complaint Processing Procedures

. OCR investigates discrimination complaints against institutions and agencies which

receive funds from the U.S. Department of Education and against public educational

entities and libraries that are subject to the provisions of Title II of the Americans

with Disabilities Act. Please identify the institution or agency that engaged in the

alleged discrimination. If we cannot accept your complaint, we will attempt to refer

it to the appropriate agency and will notify you of that fact.

Name of Institution: _______________________________________________________________________________

Address: _____________________________________________________________________________________________

City:_______________________________________________ State:_______________ Zip Code:_________________

Department/School: ______________________________________________________________________________

4. The regulations OCR enforces prohibit discrimination on the basis of race, color,

national origin, sex, disability, age or retaliation. Please indicate the basis of your

complaint:

□ Discrimination based on race (specify)

_____________________________________________________________________________________

______________________________________________________________________________________

□ Discrimination based on color (specify)

_____________________________________________________________________________________

______________________________________________________________________________________

□ Discrimination based on national origin (specify)

______________________________________________________________________________________

_____________________________________________________________________________________

______________________________________________________________________________________

□ Discrimination based on sex (specify)

_____________________________________________________________________________________

______________________________________________________________________________________

Page 3 of 12 – U.S. Department of Education, Office for Civil Rights Discrimination

Complaint Form, Consent Form, and Complaint Processing Procedures

□ Di

scrimination based on disability (specify)

______________________________________________________________________________________

□ Discrimination based on age (specify)

______________________________________________________________________________________

□ Retaliation because you filed a complaint or asserted your rights (specify)

______________________________________________________________________________________

□ Violation of the Boy Scouts of America Equal Access Act (specify)

______________________________________________________________________________________

5. Please describe each alleged discriminatory act. For each action, please include the

date(s) the discriminatory act occurred, the name(s) of each person(s) involved and,

why you believe the discrimination was because of race, disability, age, sex, etc. Also

please provide the names of any person(s) who was present and witnessed the

act(s) of discrimination.

______________________________________________________________________________________

Page 4 of 12 – U.S. Department of Education, Office for Civil Rights Discrimination

Complaint Form, Consent Form, and Complaint Processing Procedures

6. What is the most recent date you were discriminated against?

Date:_______________________________________________________________________________

7. If this date is more than 180 days ago, you may request a waiver of the filing

requirement

□ I

am requesting a waiver of the 180-day time frame for filing this complaint.

Please explain why you waited until now to file your complaint.

______________________________________________________________________________________

8. Have you attempted to resolve these allegations with the institution through an

internal grievance procedure, appeal or due process hearing?

□ YES □ NO

If you answered yes, please describe the allegations in your grievance or hearing,

identify the date you filed it, and tell us the status. If possible, please provide us

with a copy of your grievance or appeal or due process request and, if completed,

the decision in the matter.

______________________________________________________________________________________

9. If the allegations contained in this complaint have been filed with any other Federal,

state or local civil rights agency, or any Federal or state court, please give details and

dates. We will determine whether it is appropriate to investigate your complaint

based upon the specific allegations of your complaint and the actions taken by the

other agency or court.

Agency or Court:_________________________________________________________________________

Date Filed: ___________________

Case Number or Reference: __________________________________________________________

Results of Investigation/Findings by Agency or Court:

______________________________________________________________________________________________

Page 5 of 12 – U.S. Department of Education, Office for Civil Rights Discrimination

Complaint Form, Consent Form, and Complaint Processing Procedures

10. If we cannot reach you at your home or work, we would like to have the name and

telephone number of another person (relative or friend) who knows where and

when we can reach you. This information is not required, but it will be helpful to

us.

Last Name:____________________ First Name:____________________ Middle Name:___________________

Home Telephone______________________________ Work Telephone:______________________________

11. What would you like the institution to do as a result of your complaint — wha

emedy are you seeking?

______________________________________________________________________________________

12. We cannot accept your complaint if it has not been signed. Please sign and date

your complaint below.

___________ __________________________________________

(Date) (Signature)

___________ __________________________________________

(Date) (Signature of person in Item 2)

Please mail the completed and signed Discrimination Complaint Form, your signed consent

form and copies of any written material or other documents you believe will help OCR

understand your complaint to the OCR Enforcement Office responsible for the state where

the institution or entity about which you are complaining is located. You can locate the

mailing information for the correct enforcement office on OCR’s website at

http://wdcrobcolp01.ed.gov/CFAPPS/OCR/contactus.cfm.

Updated April 2014

CONSENT FORM - FOR REVEALING NAME AND PERSONAL INFORMATION TO OTHERS

(Please print or type except for signature line)

Your Name: __________________________________________________________________________

Name of School or Other Institution That You Have Filed This Complaint Against: ______________

_____________________________________________________________________________________

 This form asks whether the Office for Civil Rights (OCR) may share your name and other personal

information when OCR decides that doing so will assist in investigating and resolving your complaint.

 For example, to decide whether a school discriminated against a person, OCR often needs to reveal that

person’s name and other personal information to employees at that school to verify facts or get additional

information. When OCR does that, OCR informs the employees that all forms of retaliation against that

person and other individuals associated with the person are prohibited. OCR may also reveal the person’s

name and personal information during interviews with witnesses and consultations with experts.

 If OCR is not allowed to reveal your name or personal information as described above, OCR may decide to

close your complaint if OCR determines it is necessary to disclose your name or personal information in

order to resolve whether the school discriminated against you.

NOTE: If you file a complaint with OCR, OCR can release certain information about your complaint to the press or

general public, including the name of the school or institution; the date your complaint was filed; the type of

discrimination included in your complaint; the date your complaint was resolved, dismissed or closed; the basic

reasons for OCR’s decision; or other related information. Any information OCR releases to the press or general

public will not include your name or the name of the person on whose behalf you filed the complaint.

NOTE: OCR requires you to respond to its requests for information. Failure to cooperate with OCR’s investigation

and resolution activities could result in the closure of your complaint.

Please sign section A or section B (but not both) and return to OCR:

 If you filed the complaint on behalf of yourself, you should sign this form.

 If you filed the complaint on behalf of another specific person, that other person should sign this form.

EXCEPTION: If the complaint was filed on behalf of a specific person who is younger than 18 years old or a

legally incompetent adult, this form must be signed by the parent or legal guardian of that person.

 If you filed the complaint on behalf of a class of people, rather than any specific person, you should sign the form.

A. I give OCR my consent to reveal my identity (and that of my minor child/ward on whose behalf the

complaint is filed) to others to further OCR’s investigation and enforcement activities.

_____________________________________ ___________________

Signature Date

B. I do not give OCR my consent to reveal my identity (and that of my minor child/ward on whose

behalf the complaint is filed) to others. I understand that OCR may have to close my complaint.

_____________________________________ ___________________

Signature Date

I declare under penalty of perjury that it is true and correct that I am the person named above; and, if the complaint is filed on behalf of a minor child/ward, that I am

that person’s parent or legal guardian. This declaration only applies to the identity of the persons and does not extend to any of the claims filed in the complaint.

Page 7 of 12 – U.S. Department of Education, Office for Civil Rights Discrimination

Complaint Form, Consent Form, and Complaint Processing Procedures

OCR COMPLAINT PROCESSING PROCEDURES

AWS ENFORCED BY OCR

CR enforces the following laws:

• Tit

le VI of the Civil Rights Act of 1964, which prohibits discrimination on the basis of

race, color or national origin;

• Title IX of the Education Amendments of 1972, which prohibits discrimination on

the basis of sex;

• Section 504 of the Rehabilitation Act of 1973, which prohibits discrimination on th

asis of disability;

• Age Discrimination Act of 1975, which prohibits discrimination on the basis of age;

• Title II of the Americans with Disabilities Act of 1990, which prohibit

iscrimination on the basis of disability;

• Boy Scouts of America Equal Access Act, part of the No Child Left Behind Act of

2001, which prohibits denial of access to or other discrimination against the Boy

Scouts or other Title 36 U.S.C. youth groups in public elementary schools, public

econdary schools, local education agencies, and state education agencies that hav

designated open forum or limited public forum.

VALUATION OF THE COMPLAINT

CR evaluates each complaint that it receives in order to determine whether it can

investigate the complaint. OCR makes this determination with respect to each allegation in

the complaint. For example, OCR must determine whether OCR has legal authority to

investigate the complaint; that is, whether the complaint alleges a violation of one or more

of the laws OCR enforces. OCR must also determine whether the complaint is filed on time.

Generally, a complaint must be filed with OCR within 180 calendar days of the last act that

the complainant believes was discriminatory.

If the complaint is not filed on time, the

complainant should provide the reason for the delay and request a waiver of this filing

requirement. OCR will decide whether to grant the waiver. In addition, OCR will determine

whether the complaint contains enough information about the alleged discrimination to

proceed to investigation. If OCR needs more information in order to clarify the complaint, it

will contact the complainant; the complainant has 20 calendar days within which to

respond to OCR’s request for information.

OCR will dismiss a complaint if OCR determines that:

• OCR does not have legal authority to investigate the complaint;

• The complaint fails to state a violation of one of the laws OCR enforces;

• The complaint was not filed timely and that a waiver will not be granted;

• The complaint is unclear or incomplete and the complainant does not provide the

information that OCR requests within 20 calendar days of OCR’s request;

• The allegations raised by the complaint have been resolved;

Complaints that allege discrimination based on age are timely if filed with OCR within 180 calendar days

of the date the complainant first knew about the alleged discrimination.

Page 8 of 12 – U.S. Department of Education, Office for Civil Rights Discrimination

Complaint Form, Consent Form, and Complaint Processing Procedures

• The complaint has been investigated by another Federal, state, or local civil rights

agency or through a recipient’s internal grievance procedures, including due proces

roceedings, and the resolution meets OCR regulatory standards or, if still pending,

OCR anticipates that there will be a comparable resolution process under comparable

egal standards;

• The same allegations have been filed by the complainant against the same recipient in

state or Federal court;

• The allegations are foreclosed by previous decisions of the Federal courts, the U.S

ecretary of Education, the U.S. Department of Education’s Civil Rights Reviewing

Authority, or OCR policy determinations.

PENING THE COMPLAINT FOR INVESTIGATION

f OCR determines that it will investigate the complaint, it will issue letters of notification to

the complainant and the recipient. Opening a complaint for investigation in no way implies

that OCR has made a determination with regard to the merits of the complaint. During the

investigation, OCR is a neutral fact-finder. OCR will collect and analyze relevant evidence

from the complainant, the recipient, and other sources as appropriate. OCR will ensure that

investigations are legally sufficient and are dispositive of the allegations raised in the

complaint.

INVESTIGATION OF THE COMPLAINT

CR may use a variety of fact-finding techniques in its investigation of a complaint. These

techniques may include reviewing documentary evidence submitted by both parties,

conducting interviews with the complainant, recipient’s personnel, and other witnesses,

and/or site visits. At the conclusion of its investigation, OCR will determine with regard to

each allegation that:

• Th

ere is insufficient evidence to support a conclusion that the recipient failed to

comply with the law, or

• A

preponderance of the evidence supports a conclusion that the recipient failed to

comply with the law.

CR’s determination will be explained in a letter of findings sent to the complainant and

recipient. Letters of findings issued by OCR address individual OCR cases. Letters of

findings contain fact-specific investigative findings and dispositions of individual cases.

Letters of findings are not formal statements of OCR policy and they should not be relied

upon, cited, or construed as such. OCR’s formal policy statements are approved by a duly

authorized OCR official and made available to the public.

RESOLUTION OF THE COMPLAINT AFTER A DETERMINATION OF NONCOMPLIANCE

f OCR determines that a recipient failed to comply with one of the civil rights laws that OCR

enforces, OCR will contact the recipient and will attempt to secure the recipient’s

willingness to negotiate a voluntary resolution agreement. If the recipient agrees to resolve

the complaint, the recipient will negotiate and sign a written resolution agreement that

describes the specific remedial actions that the recipient will undertake to address the

area(s) of noncompliance identified by OCR. The terms of the resolution agreement, if fully

performed, will remedy the identified violation(s) in compliance with applicable civil rights

laws. OCR will monitor the recipient’s implementation of the terms of the resolution

Page 9 of 12 – U.S. Department of Education, Office for Civil Rights Discrimination

Complaint Form, Consent Form, and Complaint Processing Procedures

agreement to verify that the remedial actions agreed to by the recipient have been

implemented consistent with the terms of the agreement and that the area(s) of

noncompliance identified were resolved consistent with applicable civil rights laws.

f the recipient refuses to negotiate a voluntary resolution agreement or does not

immediately indicate its willingness to negotiate, OCR will inform the recipient that it has

30 days to indicate its willingness to engage in negotiations to voluntarily resolve identified

areas of noncompliance, or OCR will issue a Letter of Finding to the parties providing a

factual and legal basis for a finding noncompliance.

If, after the issuance of the Letter of Finding of noncompliance, the recipient continues to

refuse to negotiate a resolution agreement with OCR, OCR will issue a Letter of Impending

Enforcement Action and will again attempt to obtain voluntary compliance. If the recipient

remains unwilling to negotiate an agreement, OCR will either initiate administrative

enforcement proceedings to suspend, terminate, or refuse to grant or continue Federal

financial assistance to the recipient, or will refer the case to the Department of Justice. OCR

may also move immediately to defer any new or additional Federal financial assistance to

the institution.

ESOLUTION OF THE COMPLAINT PRIOR TO THE CONCLUSION OF THE

INVESTIGATION

arly Complaint Resolution (ECR):

arly Complaint Resolution allows the parties (the complainant and the institution which is

the subject of the complaint) an opportunity to resolve the complaint allegations quickly;

generally, soon after the complaint has been opened for investigation. If both parties are

willing to try this approach, and if OCR determines that Early Complaint Resolution is

appropriate, OCR will facilitate settlement discussions between the parties and work with

the parties to help them understand the legal standards and possible remedies. To the

extent possible, staff assigned by OCR to facilitate the Early Complaint Resolution process

will not be the staff assigned to the investigation of the complaint.

OCR does not approve, sign or endorse any agreement reached between the parties as a

result of Early Complaint Resolution, and OCR does not monitor the agreement. However, if

the recipient institution does not comply with the terms of the agreement, the complainant

may file another complaint with OCR within 180 days of the date of the original

discrimination or within 60 days of the date the complainant learns of the failure to comply

with the agreement, whichever date is later.

Resolution of the Complaint Prior To the Conclusion of an Investigation

complaint may also be resolved before the conclusion of an investigation, if the recipient

expresses an interest in resolving the complaint. If OCR determines that resolution of the

complaint before the conclusion of an investigation is appropriate, OCR will attempt to

negotiate an agreement with the recipient. OCR will notify the complainant of the

recipient’s request and will keep the complainant informed throughout all stages of the

resolution process. The provisions of the resolution agreement that is reached must be

aligned with the complaint allegations and the information obtained during the

investigation, and must be consistent with applicable regulations. A resolution agreement

reached before the conclusion of an investigation will be monitored by OCR.

Page 10 of 12 – U.S. Department of Education, Office for Civil Rights

Discrimination Complaint Form, Consent Form, and Complaint Processing Procedures

APPEAL OF OCR’S DETERMINATIONS

OCR is committed to a high quality resolution of every case. OCR affords an opportunity to

the complainant to submit an appeal of OCR's letter finding insufficient evidence of a

violation. The appeal process provides an opportunity for complainants to bring

information to OCR’s attention that would change OCR’s decision. The appeal process will

not be a de novo review of OCR’s decision (i.e., OCR will not review the matter as if no

previous decision had been rendered).

f the complainant disagrees with OCR’s decision, he or she may send a written appeal to the

Director of the Enforcement Office (Office Director) that issued the determination. If the

complainant has documentation to support the appeal, the documentation must be

submitted with the complainant’s appeal. In an appeal, the complainant must explain why

he or she believes the factual information was incomplete, the analysis of the facts was

incorrect, and/or the appropriate legal standard was not applied, and how this would

change OCR’s determination in the case. Failure to do so may result in the denial of the

appeal.

In order to be timely, an appeal (including any supporting documentation) must be

submitted within 60 days of the date of the determination letter. The Office Director may

exercise discretion in granting a waiver of the 60-day timeframe where:

1. the complainant was unable to submit the appeal within the 60-day timeframe

because of illness or other incapacitating circumstances and the appeal was filed

within 30 days after the period of illness or incapacitation ended; or

2. unique circumstances generated by agency action have adversely affected the

complainant.

A written response to an appeal will be issued. A decision of the Office Director constitutes

the agency’s final decision. Such a decision will inform the complainant that he or she

"may have the right to file a private suit in federal court whether or not OCR finds a

violation."

DDITIONAL INFORMATION

Right to File a Separate Court Action

The complainant may have the right to file suit in Federal court, regardless of OCR’s

findings. OCR does not represent the complainant in case processing, so if the complainant

wishes to file a court action, he or she must do so through his or her own attorney or on his

or her own through the court’s pro se clerk’s office.

If a complainant alleges discrimination prohibited by the Age Discrimination Act of 1975, a

civil action in Federal court can be filed only after the complainant has exhausted

administrative remedies. Administrative remedies are exhausted when either of the

following has occurred:

Page 11 of 12 – U.S. Department of Education, Office for Civil Rights

Discrimination Complaint Form, Consent Form, and Complaint Processing Procedures

1) 180 days have elapsed since the complainant filed the complaint with OCR and

OCR has made no finding; or

2) OCR issues a finding in favor of the recipient. If this occurs, OCR will promptly

notify the complainant and will provide additional information about the right to file

for injunctive relief.

Prohibition against Intimidation or Retaliation

An institution under the jurisdiction of the Department of Education may not intimidate,

threaten, coerce, or retaliate against anyone who asserts a right protected by the civil rights

laws that OCR enforces, or who cooperates in an investigation. Anyone who believes that he

or she has been intimidated or retaliated against should file a complaint with OCR.

Investigatory Use of Personal Information

In order to investigate a complaint, OCR may need to collect and analyze personal

information such as student records or employment records. No law requires anyone to

give personal information to OCR and no formal sanctions will be imposed on complainants

or other persons who do not cooperate in providing information during the complaint

investigation and resolution process. However, if OCR is unable to obtain the information

necessary to investigate a complaint, we may have to close the complaint.

The Privacy Act of 1974, 5 U.S.C. § 552a, and the Freedom of Information Act (FOIA), 5 U.S.C.

§ 552, govern the use of personal information that is submitted to all Federal agencies and

their individual components, including OCR. The Privacy Act of 1974 protects individuals

from the misuse of personal information held by the Federal government. It applies to

records that are maintained by the government that are retrieved by the individual's name,

social security number, or other personal identifier. It regulates the collection, maintenance,

use and dissemination of certain personal information in the files of Federal agencies.

The information that OCR collects is analyzed by authorized personnel within the agency

and will be used by the government only for authorized civil rights compliance and

enforcement activities. However, in order to investigate or resolve a complaint, OCR may

need to reveal certain information to persons outside the agency to verify facts or gather

additional information. Such details could include the name, age, or physical condition of the

person who is the alleged subject of discrimination. Also, OCR may be required to reveal

information requested under FOIA, which gives the public the right of access to records of

Federal agencies. OCR will not release any information about a complainant to any other

agency or individual except in the one of the 11 instances defined in the Department's

regulation at 34 C.F.R. § 5b.9(b).

OCR does not reveal the name or other identifying information about an individual

(including individuals who file complaints or speak to OCR) unless (1) such information

would assist in the completion of an investigation or for in enforcement activities against an

institution that violates the laws, or; (2) unless such information is required to be disclosed

under the FOIA or the Privacy Act. OCR will keep the identity of complainants confidential

except to the extent necessary to carry out the purposes of the civil rights laws, or unless

disclosure is required under the FOIA, the Privacy Act or otherwise by law; or (3) such

Page 12 of 12 – U.S. Department of Education, Office for Civil Rights

Discrimination Complaint Form, Consent Form, and Complaint Processing Procedures

information is permitted to be disclosed under both FOIA and the Privacy Act and OCR

determines disclosure would further an interest of the Department and the United States.

However, OCR can release certain information about your complaint to the press or general

public, including the name of the school or institution; the date your complaint was filed;

the type of discrimination included in your complaint; the date your complaint was

resolved, dismissed or closed; the basic reasons for OCR’s decision; or other related

information. Any information OCR releases to the press or general public will not include

your name or the name of the person on whose behalf you filed the complaint except as

noted in the paragraph above.

FOIA gives the public the right of access to records and files of Federal agencies. Individuals

may obtain items from many categories of records of the Federal government, not just

materials that apply to them personally. OCR must honor requests for records under FOIA,

with some exceptions. Generally, OCR is not required to release documents during the case

evaluation and investigation process or enforcement proceedings, if the release could

reasonably be expected to interfere with the affect the ability of OCR to do its job. 5 U.S.C. §

552(b)(7)(A). Also, a Federal agency may refuse a request for records if their release would

or could reasonably be expected to result in an unwarranted invasion of privacy of an

individual. 5 U.S.C. § 552(b)(6) and (7)(C). Also, a request for other records, such as medical

records, may be denied where disclosure would be a clearly unwarranted invasion of

privacy.

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