Fill - Free fillable United States Department of Education Office for Civil (U.S. Department of Education) PDF form

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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 twelve 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.

Befor

e 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:_________

__________

Addres

s: _____________________________________________________________________________________________

City:_______________________________________________ State:___ Zip Code:__

___________________________

Home Telephone:______________________________ Work Telephone:______________________________

E-mail Address: ____________________________________________________________________________________

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

discriminated 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 this

complaint. 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:___________________

Addre

ss: ___ _______

___________________________________________________________________________________

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

3. OC

R 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:___ Zi

p 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)

_____________________________________________________________________________________

__

____________________________________________________________________________________

______________________________________________________________________________________

□ Dis

crimination based on color (specify)

_____________________________________________________________________________________

__

____________________________________________________________________________________

______________________________________________________________________________________

□ Dis

crimination based on national origin (specify)

______________________________________________________________________________________

__

___________________________________________________________________________________

______________________________________________________________________________________

□ Dis

crimination 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

□ Discr

imination based on disability (specify)

______________________________________________________________________________________

□ D

iscrimination based on age (specify)

______________________________________________________________________________________

□

Ret

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

______________________________________________________________________________________

□ Vi

olation 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?

D

ate:

_______________________________________________________________________________

7. I

f 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. H

ave 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 t

he 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.

A

gency or Court:

_________________________________________________________________________

D

ate Filed:

___________________

C

ase Number or Reference:

__________________________________________________________

R

esults 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.

L

ast Name:

____________________ First Name: Middle Name:___________________ ____________________

Ho

me Telephone

__ Work Telephone:______________________________ ____________________________

11. W

hat would you like the institution to do as a result of your complaint — what

remedy are you seeking?

______________________________________________________________________________________

12. W

e 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

OR

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.

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