Form OMB 1190-0008 OMB 1190-0008 Complaint Form

Complaint Form, Federal Coordination and Compliance Section, Civil Rights Division, U.S. Department of Justice

Updated COMPLAINT FORM

Complaint Form, Federal Coordination and Compliance Section, Civil Rights Division, U.S. Department of Justice

OMB: 1190-0008

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1190-0008 can be found here:

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COMPLAINT FORM

The purpose of this form is to assist you in filing a complaint with the Federal Coordination and Compliance Section. You are not required to use this form; a letter with the same information is sufficient. However, the information requested in the items marked with a star (*) must be provided, whether or not this form is used.

1.* State your name and address.

Name: ________________________________________________________________________

Address: _______________________________________________________________________

_____________________________________________________________ Zip ______________

Telephone: Home: (_____)___________________ Work or Cell: (_____)___________________

2.* Person(s) discriminated against, if different from above:

Name: ________________________________________________________________________

Address: _______________________________________________________________________

_____________________________________________________________ Zip ______________

Telephone: Home: (_____)___________________ Work or Cell: (_____)___________________

Please explain your relationship to this person(s).

3.* Agency and department or program that discriminated:

Name: ________________________________________________________________________

Address: _______________________________________________________________________

_____________________________________________________________ Zip ______________

Telephone: Home: (_____)___________________ Work or Cell: (_____)___________________

4A.* Non-employment: Does your complaint concern discrimination in the delivery of services or in other discriminatory actions of the department or agency in its treatment of you or others? If so, please indicate below the base(s) on which you believe these discriminatory actions were taken.

____ Race/Ethnicity: ______________________________________

____ National origin: ______________________________________

____ Sex: _______________________________________________

____ Religion: ___________________________________________

____ Age: _______________________________________________

____ Disability: __________________________________________

4B.* Employment: Does your complaint concern discrimination in employment by the department or agency? If so, please indicate below the base(s) on which you believe these discriminatory actions were taken.

____ Race/Ethnicity: ______________________________________

____ National origin: ______________________________________

____ Sex: _______________________________________________

____ Religion: ___________________________________________

____ Age: _______________________________________________

____ Disability: __________________________________________

5. What is the most convenient time and place for us to contact you about this complaint?

___________________________________________________________________

6. If we will not be able to reach you directly, you may wish to give us the name and phone number of a person who can tell us how to reach you and/or provide information about your complaint:

Name: ___________________________________________________________________

Telephone: Home:(_____)_________________ Work or Cell: (_____)_______________

7. If you have an attorney representing you concerning the matters raised in this complaint, please provide the following:

Name: ________________________________________________________________________

Address: ______________________________________________________________________

_____________________________________________________________ Zip_____________

Telephone: Home: (_____)__________________Work or Cell: (_____)___________________

8.* To your best recollection, on what date(s) did the alleged discrimination take place?

Earliest date of discrimination: _________________

Most recent date of discrimination: _________________

9. Complaints of discrimination must generally be filed within 180 days of the alleged discrimination. If the most recent date of discrimination, listed above, is more than 180 days ago, you may request a waiver of the filing requirement. If you wish to request a waiver, please explain why you waited until now to file your complaint.

_____________________________________________________________________________

10.* Please explain as clearly as possible what happened, why you believe it happened, and how you were discriminated against. Indicate who was involved. Be sure to include how other persons were treated differently from you. (Please use additional sheets if necessary and attach a copy of written materials pertaining to your case.)

_____________________________________________________________________________

11. The laws we enforce prohibit recipients of Department of Justice funds from intimidating or

retaliating against anyone because he or she has either taken action or participated in action to

secure rights protected by these laws. If you believe that you have been retaliated against

(separate from the discrimination alleged in #10), please explain the circumstances below. Be

sure to explain what actions you took which you believe were the basis for the alleged

retaliation.

_____________________________________________________________________________

12. Please list below any persons (witnesses, fellow employees, supervisors, or others), if known, whom we may contact for additional information to support or clarify your complaint.

Name Address Area Code/Telephone

_____________________________________________________________________________

13. Do you have any other information that you think is relevant to our investigation of your allegations?

_____________________________________________________________________________

14. What remedy are you seeking for the alleged discrimination?

_____________________________________________________________________________

15. Have you (or the person discriminated against) filed the same or any other complaints with other offices of the Department of Justice (including the Office of Justice Programs, Federal Bureau of Investigation, etc.)?

Yes ____ No ____

If so, do you remember the Complaint Number?

_____________________________________________________

Against what agency and department or program was it filed?

______________________________________________________________________________

Address: ______________________________________________________________________

_______________________________________________________ Zip __________________

Telephone No: (____)_______________

Date of Filing: ____________________ DOJ Agency:__________________________________

Briefly, what was the complaint about?

_____________________________________________________________________________

What was the result?

_____________________________________________________________________________

16. Have you filed or do you intend to file a charge or complaint concerning the matters raised in this complaint with any of the following?

_____ U.S. Equal Employment Opportunity Commission

_____ Federal or State Court

_____ Your State or local Human Relations/Rights Commission

_____ Grievance or complaint office

17. If you have already filed a charge or complaint with an agency indicated in #16, above, please provide the following information (attach additional pages if necessary):

Agency: _____________________________________________________________________

Date filed: ____________________________________

Case or Docket Number: ________________________

Date of Trial/Hearing: __________________________

Location of Agency/Court: _______________________________________________________

Name of Investigator: ___________________________________________________________

Status of Case: _________________________________________________________________

Comments: ____________________________________________________________________

______________________________________________________________________________

18. While it is not necessary for you to know about aid that the agency or institution you are filing against receives from the Federal government, if you know of any Department of Justice funds or assistance received by the program or department in which the alleged discrimination occurred, please provide that information below.

_____________________________________________________________________________

19.* We cannot accept a complaint if it has not been signed. Please sign and date this Complaint Form below.

_______________________________________________ ____________________

(Signature) (Date)

Please feel free to add additional sheets to explain the present situation to us.

We will need your consent to disclose your name, if necessary, in the course of any investigation. Therefore, we will need a signed Consent Form from you. (If you are filing this complaint for a person whom you allege has been discriminated against, we will in most instances need a signed Consent Form from that person.) See the "Notice about Investigatory Uses of Personal Information" for information about the Consent Form. Please mail the completed, signed Discrimination Complaint Form and the signed Consent Form (please make one copy of each for your records) to:

United States Department of Justice

Civil Rights Division

Federal Coordination and Compliance Section - NWB

950 Pennsylvania Avenue, NW

Washington, D.C. 20530

Toll-free Voice and TDD: (888) 848-5306

Voice: (202) 307-2222

TDD: (202) 307-2678

20. How did you learn that you could file this complaint?

_____________________________________________________________________________

21. If your complaint has already been assigned a DOJ complaint number, please list it here:

_______________________________________

Note: If a currently valid OMB control number is not displayed on the first page, you are not required to fill out this complaint form unless the Department of Justice has begun an administrative investigation into this complaint.

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File Type	application/msword
Author	ekeenan
Last Modified By	Lynn Bryant
File Modified	2011-01-31
File Created	2011-01-31