Form DHS Form 3095 DHS Form 3095 DHS Civil Rights Compliance Form

DEPARTMENT OF HOMELAND SECURITY

OMB Control No. 1601-NEW
Expiration Date MM/DD/YYYY

CIVIL RIGHTS COMPLIANCE FORM
Section 1: Instructions

Entities selected to receive a grant, cooperative agreement, or other award of Federal financial assistance from the U.S.
Department of Homeland Security (DHS) or one of its Components must complete this form and submit all required data within thirty
(30) days of receipt of the Notice of Award or, for State Administering Agencies, thirty (30) days from receipt of this form from DHS
or its awarding component. Recipients are required to provide this information once every two (2) years, not every time a grant is
awarded. Entities whose award does not run a full two (2) years are required to provide the information again if they receive a
subsequent award more than two (2) years after the prior award.
Please refer to Section 6 for instructions on submitting the completed form and all supporting documentation to DHS. Submission of
a completed form, including supporting materials, by the deadline, is required to meet regulatory compliance requirements. This form
clarifies the recipient’s civil rights obligations and related reporting requirements contained in the
DHS Standard Terms and Conditions.
For State Administering Agencies:
State Administering Agencies will receive this form directly from DHS, rather than in conjunction with a Notice of Award, and must
complete this form and submit all required data within thirty (30) days of receipt. State Administering Agencies, like other recipients,
are required to provide this information once every two (2) years, not every time a grant is awarded.
For Subrecipients:
Subrecipients are entities to whom Federal financial assistance is extended though another recipient, and do not receive financial
assistance directly from DHS. Subrecipients are not required to complete and submit this form to DHS. However, subrecipients have
the same obligations as their primary recipient to comply with applicable civil rights requirements and should follow their primary
recipient’s procedures regarding the submission of civil rights information.

Section 2: Organization Information
Organization Name:

DUNS Number:

Address (Street, City, State, Zip code):
Contact Person / Title:
Email / Telephone:
Grant Agreement Number:

Federal Award Identification Number:

Section 3: Assurance to Comply with Civil Rights Requirements
As a condition of receipt of Federal financial assistance, the recipient acknowledges and agrees that it is in compliance at the time of
signing this document and will continue to be in compliance for the duration of the Federal financial assistance (and require any
subgrantees, contractors, successors, transferees, and assignees to comply) with applicable provisions of laws and policies
prohibiting discrimination, including but not limited to:

•

Title VI of the Civil Rights Act of 1964, as amended, which prohibits recipients of Federal financial assistance from
discriminating on the basis of race, color, or national origin (42 U.S.C. 2000d et seq.), as implemented by DHS Title VI
regulation 6 C.F.R Part 21, and FEMA Title VI regulation 44 C.F.R. Part 7.
o

Language Access: National origin discrimination includes discrimination on the basis of limited English proficiency (LEP).
To ensure compliance with Title VI, recipients must take reasonable steps to ensure that LEP persons have meaningful
access to its programs and activities. Providing meaningful access for persons with LEP may entail providing language
assistance services, including oral interpretation and written translation. Recipients are encouraged to consider the need for
language services for LEP persons served or encountered both in developing budgets and in conducting programs and
activities. Recipients should follow agency guidance: Guidance to Federal Financial Assistance Recipients Regarding the
Title VI Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons (see link below in
Section 7).

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•

o

Environmental Justice: In accordance with Title VI, recipients must ensure that all programs or activities receiving Federal
financial assistance that affect human health or the environment do not directly, or through contractual or other
arrangements, use criteria, methods, or practices that discriminate on the basis of race, color, or national origin.

o

Property: Where the Federal financial assistance is to provide or is in the form of personal property, or real property or
interest therein or structures thereon, this assurance shall obligate the recipient and any transferee to comply with all
applicable requirements imposed by 6 C.F.R Part 21 and 44 C.F.R. Part 7 for the period during which the property is used
for the purpose for which the Federal financial assistance is extended or for another purpose involving the provision of
similar services or benefits, or for as long as the recipient retains ownership or possession of the property, whichever is
longer.

Section 504 of the Rehabilitation Act of 1973, as amended, which prohibits discrimination on the basis of disability (29 U.S.C.
794), provides that no otherwise qualified individual with a disability in the United States will, solely by reason of the disability,
be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity
receiving Federal financial assistance. These requirements pertain to the provision of benefits or services as well as to
employment.
o

In order to ensure compliance, recipients must provide program access, ensure effective communication, and provide
physical access for persons with disabilities. Recipients are encouraged to consider the need for accessibility and
reasonable accommodations and modifications for persons with disabilities both in developing budgets and in conducting
programs and activities.

o

Americans with Disabilities Act: Recipients may also have obligations under the Americans with Disabilities Act of 1990
(ADA), which prohibits recipients from discriminating on the basis of disability in the operation of public entities, public and
private transportation systems, places of public accommodation, and certain testing entities (42 U.S.C. §§ 12101–12213).
The U.S. Department of Justice (DOJ) has the lead responsibility for the enforcement of the ADA, with other federal
agencies having enforcement responsibilities for specific areas such as employment, transportation, and
telecommunications.

•

Title IX of the Education Amendments of 1972, as amended, which prohibits discrimination on the basis of sex in education
programs or activities (20 U.S.C. 1681 et seq.) as implemented by DHS Title IX regulations 6 C.F.R. Part 17, and FEMA Title
IX regulations 44 C.F.R Part 19.

•

Age Discrimination Act of 1975, as amended, which prohibits discrimination on the basis of age (42 U.S.C. 6101 et seq.) as
implemented by FEMA Age Discrimination Act regulations, 44 C.F.R. Part 7.

•

DHS regulation 6 C.F.R. Part 19: Nondiscrimination in Matters Pertaining to Faith-based Organizations, which prohibits
organizations that receive financial assistance from DHS for a social service program from discriminating against beneficiaries
on the basis of religion or religious belief, a refusal to hold a religious belief, or a refusal to attend or participate in a religious
practice, and generally requires recipients subject to the regulation to provide certain protections, and notice of those
protections, to their beneficiaries.

The United States has the right to seek judicial and administrative enforcement of this assurance document.

Section 4: Required Information: Recipients of Federal financial assistance from DHS must provide the following compliance
information in accordance with the nondiscrimination authorities listed in Section 3. State Administering Agencies must provide this
information for their own agency and also describe how subrecipients are monitored (see Item 7).

Note: For recipients who have previously submitted this form in the last two (2) years, if the information provided in response to any
of the items below has not changed since the last submission, and there are no additional updates, please indicate “no change”
under each applicable item; do not re-submit information previously submitted.
1.

Provide a brief description of any complaints or lawsuits against the recipient during the past five (5) years alleging
discrimination on the basis of race, color or national origin (including limited English proficiency), sex, age, disability, or
alleging retaliation. The description should distinguish employment-related complaints or lawsuits from non-employment
related complaints or lawsuits and include the following information: total number of complaints or lawsuits by protected bases
and status (pending, closed with findings, closed with no findings). Additionally, if a court or administrative agency made a
finding of discrimination against the recipient during the past five (5) years, the recipient must forward a copy of the complaint
and findings to DHS.
The recipient agrees to notify DHS, within sixty (60) days of receipt, of any such lawsuits against the recipient or any findings
of discrimination against the recipient that occur throughout the duration of Federal financial assistance.
Responses should not include personally identifiable information (PII) that is outside of public record. PII is any
information that permits the identity of an individual to be directly or indirectly inferred, including any information
which is linked or linkable to an individual.

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2.

Provide a brief description of any civil rights compliance reviews regarding the recipient conducted during the two (2) year
period before this award of DHS Federal financial assistance, and provide information concerning the agency or organization
performing the review. The recipient agrees to provide periodic updates of such ongoing reviews, including any findings made
by such reviews, and to promptly notify DHS of any additional compliance reviews for the duration of the Federal financial
assistance.

3.

Provide a list of all other federal agencies from whom the recipient receives financial assistance or has a pending application
for financial assistance at the time of this award of DHS Federal financial assistance. The recipient agrees to notify DHS, for
the duration of the DHS Federal financial assistance, of any new applications for financial assistance from federal agencies not
previously reported on this form.

3a.

State whether any agency listed by the recipient in response to Section 4, no. 3 has found the recipient to be in
noncompliance with any civil rights requirements.

4.

Provide a statement affirming that staff has been designated to coordinate and carry out the responsibilities for compliance
with civil rights laws, a description of the responsibilities of any such staff, and a list of all federal civil rights laws that the staff
coordinates and enforces.

5.

Provide a copy of the recipient’s nondiscrimination policy stating that programs and services will be provided without regard to
race, color, national origin, disability, sex, or age, as required by Title VI of the Civil Rights Act of 1964, Section 504 of the
Rehabilitation Act of 1973, Title IX of the Education Amendments Act of 1972, and the Age Discrimination Act of 1975. The
policy should also state that Federal law prohibits retaliatory acts against any individual involved in a complaint, investigation,
or other proceeding related to prohibited discrimination.

6.

Provide a copy of the recipient’s discrimination complaints process.

7.

Provide a copy of the recipient’s plan to ensure compliance in subrecipient programs (if applicable). The plan should describe
how the recipient will ensure that subrecipients conducting portions of covered programs or activities and subcontractors
conducting contracted or subcontracted portions of programs or activities comply with the nondiscrimination provisions.

8.

Provide copies of the recipient’s policy and procedures used to ensure nondiscrimination based on disability and equal
opportunity for persons with disabilities to participate in and benefit from the recipient’s programs and activities, including
policy and procedures for providing program access, procedures to ensure effective communication with individuals who are
deaf or hard of hearing, are blind or have low vision, have speech disabilities, or have intellectual or developmental disabilities,
and policy and procedures for providing physical access to the recipient’s facilities.

9.

Provide copies of the recipient’s policy and procedures regarding the requirement to provide meaningful access to programs
and services to individuals with limited English proficiency (LEP).

DHS may request additional information from the recipient, as necessary, to ascertain compliance with relevant civil rights
requirements. Examples include, but are not limited to, program beneficiary data by race, color, and national origin, a self-evaluation
with regard to the recipient’s compliance with Section 504 of the Rehabilitation Act of 1973, etc. Please refer to the DOJ regulation
on Coordination of Enforcement of Non-discrimination in Federally Assisted Programs (28 C.F.R 42.406(b)).

Section 5: Certification
I certify that the statements I have made on this form and all attachments thereto are true, accurate and complete.
Name and Title of Authorized Official:

Date:

Section 6: Instructions for Submitting Responses
Submit completed forms and all supporting documentation to:
CivilRightsComplianceForm@hq.dhs.gov

Section 7: Additional Information
Compliance resources for recipients:
http://dhs.gov/resources-recipients-dhs-financial-assistance
Information on obligations regarding nondiscrimination on the basis of race, color, and national origin:
https://www.dhs.gov/publication/title-vi-dhs
Information on obligations regarding persons with LEP:
http://www.dhs.gov/guidance-published-help-department-supported-organizations-provide-meaningful-access-people-limited
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Information on obligations regarding persons with disabilities:
http://www.dhs.gov/disability-access-department-homeland-security
For questions and assistance with this form, please contact:
DHS Office for Civil Rights and Civil Liberties
Email: CivilRightsComplianceForm@hq.dhs.gov
Phone: 202-401-1474
Toll Free: 1-866-644-8360
TTY: 202-401-0470
Toll Free TTY: 1-866-644-8361
Federal Emergency Management Agency, Office of Equal Rights (for FEMA recipients):
Email: fema-civil-rights-form@fema.dhs.gov
Phone: 202-646-3535
Paperwork Reduction Act
The public reporting burden to complete this information collection is estimated at 8 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and the completing and
reviewing the collected information. The collection of information is mandatory. An agency may not conduct or sponsor, and a
person is not required to respond to a collection of information unless it displays a currently valid OMB control number and
expiration date. Send comments regarding this burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden to:
ATTN: PRA [OMB Control No.1601-NEW].
Office for Civil Rights and Civil Liberties
U.S. Department of Homeland Security
Building 410, Mail Stop #0190
Washington, D.C. 20528

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DHS Form 3095 (12/16)

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