Fillable Form 1: Civil Rights Division Report a civil (Department of Justice)

Fill Online, Printable, Fillable, Blank Form 1: Civil Rights Division Report a civil (Department of Justice) Form

Use Fill to complete blank online DEPARTMENT OF JUSTICE (MD) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 1: Civil Rights Division Report a civil (Department of Justice)

On average this form takes 13 minutes to complete

The Form 1: Civil Rights Division Report a civil (Department of Justice) form is 7 pages long and contains:

  • 0 signatures
  • 16 check-boxes
  • 43 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Department of Justice

BROWSE DEPARTMENT OF JUSTICE (MD) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Page 1
U.S. Department of Justice
Civil Rights Division Report a civil rights violation
If you believe you or someone else has experienced a civil rights violation, please tell us
what happened. Before starting, you can also read the instructions for this form (page 8)
and what to expect after submission.
You are not required to provide your name or contact information. If you want to remain anonymous, leave this
section blank. If you choose to provide your contact information, we will only use it to respond to your submission.
1
Contact
First name Last name
Email
Phone
Mailing address 1
Mailing address 2
City State
Zip code
Are you now or have ever been an active duty service member?
If you’re reporting on behalf of someone else, please select their status.
Yes No
OMB No. 1190-0020
Expires: 4/30/2023
U.S. Department of Justice
Civil Rights Division Report a civil rights violation
2
Primary concern
What is your primary reason for contacting the Civil Rights Division?
Select the primary reason that best describes your concern. Each reason lists examples of civil rights violations that
may relate to your incident. In another section of this report, you will be able to describe your concern in your own words.
Note: Some primary concerns have follow-up questions. If you select one of these, we ask that you also answer the
follow-up question presented below the specific primary reason.
Workplace discrimination or other employment-related problem
Examples:
• Fired, not hired, or demoted for reasons unrelated to job performance or qualifications
• Retaliated against for reporting discrimination
• Inappropriately asked to provide immigration documentation
• Denied reemployment or fired based on military service
• Denied an accommodation for a disability, including not being allowed to have a service
animal in the workplace
Was this a public or private employer? *
Public employer Private employer I'm not sure
How large is this employer?
Fewer than 15 employees 15 or more employees I'm not sure
Housing discrimination or harassment
Examples:
• Denied housing, a permit, or a loan based on personal characteristics like race, sex, and/or
having children under 18 years old
• Harassment by a landlord or another tenant, including sexual harassment
• Challenges with terminating a lease due to military status change
• Denied an accommodation for a disability, including not being allowed to have a service or
assistance animal in public housing
( * ) Public employers include organizations funded by the government like the military, post office, fire
department, courthouse, DMV, or public school. This could be at the local or state level. Private employers are
business or non-profits not funded by the government such as retail stores, banks, or restaurants.
OMB No. 1190-0020
Page 2 Expires: 4/30/2023
2
U.S. Department of Justice
Civil Rights Division Report a civil rights violation
Primary concern, continued
Mistreated by police, correctional staff, or inmates
(Including while in prison)
Examples:
• Police brutality or use of excessive force, including patterns of police misconduct
• Searched and arrested under false pretenses, including racial or other discriminatory
profiling
• Denied rights while arrested or incarcerated
• Denied access to safe living conditions or accommodations for a disability, language
barrier, or religious practice while incarcerated
Did this happen while in custody or incarcerated?
Yes No
Discrimination at a school, educational program or service, or related to
receiving education *
Examples:
• Harassment based on race, sex, national origin, disability, or religion
• Denied admission or segregated in an education program or activity
• Denied educational accommodations for a disability or language barrier
Did this happen at a public or a private school, educational program or activity?
Public school or educational program I'm not sure
Private school or educational program
Voting rights or ability to vote affected
Examples:
• Obstacles to registering to vote, obtaining or submitting a ballot, having your ballot counted,
or entering a polling place to vote
• Denied adequate voting assistance or accommodations for a disability at a polling place
• Restricted or prevented from participating in an election, including voting, becoming a
candidate, or being elected for office
( * ) Includes schools, educational programs, or educational activities, like training programs, sports teams, clubs,
or other school-sponsored activities
OMB No. 1190-0020
Page 3 Expires: 4/30/2023
2
U.S. Department of Justice
Civil Rights Division Report a civil rights violation
Primary concern, continued
Discriminated against in a commercial location or public place
This could include a store, restaurant, bar, hotel, place of worship, library, medical facility, bank,
courthouse, government building, public park or street, as well as online.
Examples:
• A physical or online location that does not provide disability accommodations
• Denied service or entry because of a perceived personal characteristic like race, sex, or
religion
• Denied an accommodation for a disability, including not being allowed to have a service
animal in a commercial or public location
Place of worship or about a place of worship
Church, synagogue, temple, religious community center
Commercial or retail building
Store, restaurant, bar, hotel, theater
Healthcare facility
Hospital or clinic (including inpatient and outpatient programs), reproductive care clinic,
state developmental institution, nursing home
Financial institution
Bank, credit union, loan services
Public space
Park, sidewalk, street, other public buildings (courthouse, DMV, city library)
Other
Please describe "Other reason" (in 10 words or fewer)
Something else happened
The examples above reflect some but not all of the civil rights violations that we address. Select this
option if you don’t see an example that applies to your situation. You will be able to tell us more later.
OMB No. 1190-0020
Page 4 Expires: 4/30/2023
U.S. Department of Justice
Civil Rights Division Report a civil rights violation
3
Location details
Please tell us the city, state, and name of the location where this incident took place. This ensures your report is
reviewed by the right people within the Civil Rights Division.
Organization name
Examples: Name of facility, business or location, school, town or city, prison, polling place, website, etc.
Street address 1
Street address 2
City State
4
Date
When did this happen?
It is important for us to know how recently this incident happened so we can take the appropriate action. If this
happened over a period of time or is still happening, please provide the most recent date.
Date
OMB No. 1190-0020
Page 5 Expires: 4/30/2023
U.S. Department of Justice
Civil Rights Division Report a civil rights violation
5
Personal characteristics
Do you believe any of these personal characteristics influenced why you were treated
this way?
There are federal and state laws that protect people from discrimination based on their personal characteristics.
Here is a list of the most common characteristics that are legally protected. Select any that apply to your incident.
Age
Disability (including temporary or recovered and including HIV and drug addiction)
Family, marital, or parental status
Gender identity (including gender stereotypes)
Genetic information (including family medical history)
Immigration/citizenship status (choosing this will not share your status)
Language
National origin (including ancestry and ethnicity)
Pregnancy
Race/color
Religion
Sex
Sexual orientation
None of these apply to me
Other reason
Please describe "Other reason" (in 10 words or fewer)
OMB No. 1190-0020
Page 6 Expires: 4/30/2023
U.S. Department of Justice
Civil Rights Division Report a civil rights violation
6
Personal Description
In your own words, describe what happened.
Please share details like:
• Time
• Names of people involved including witnesses if there are any
• Any supporting materials (please list and describe them)
You may attach further details as extra pages, if necessary
OMB No. 1190-0020
Page 7 Expires: 4/30/2023
U.S. Department of Justice
Civil Rights Division Report a civil rights violation
Instructions
The purpose of this form is to assist you in filing a report with the Civil Rights Division. You are not required to
use this form; a letter with the same information is sufficient, however, please ensure you are including the same
information.
Step 1: You can complete and submit this form. By completing this form, you can provide the details we need to
understand what happened. You can mail a printed copy of this form via postal service to the division or you can
email an electronic copy. Once we receive your report, it is immediately sent to our staff for review.
Step 2: We will review your report. Teams that specialize in handling your type of issue will review it. If it needs
to be forwarded to another team or agency, we will try to connect your complaint to the right group.
Step 3: We will determine next steps and get back to you. Possible outcomes include: following up for more
information, starting a mediation or investigation, directing you to another organization for further help, or
informing you that we cannot help.
To mail a printed copy of the form: To email an electronic copy of the form:
U.S. Department of Justice
Civil Rights Division
950 Pennsylvania Avenue, NW
Washington, D.C. 20530-0001
Ask.CRT@usdoj.gov
To reach us by phone:
(202) 514-3847
1-855-856-1247 (toll-free)
Telephone Device for the Deaf
(TTY) (202) 514-0716
Privacy Policy
The purpose of this form is to allow the public to submit civil rights complaints to the Department of Justice, thereby allowing us to
enforce over thirty civil rights statutes (https://civilrights.justice.gov/privacy-policy#our-statutes) within our authority. These statutes
authorize us to collect this information. You should know that any information you provide through this form is voluntary, yet failure to
provide some of the information might limit the Department’s ability to pursue your claim. We may use this information for certain routine
uses, including sharing this information under certain circumstances with:
• contractors who work with us, if they need it to perform a contract;
• a court, magistrate, or administrative tribunal, as well as opposing counsel during settlement negotiations and/or litigation;
• Members of Congress;
• Federal, state, or local law enforcement agencies.
You can find our complete Privacy Policy at https://civilrights.justice.gov/privacy-policy.
OMB No. 1190-0020
Page 8 Expires: 4/30/2023
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 1: Civil Rights Division Report a civil (Department of Justice)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 9 April 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document