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 EVALUATION TOOL

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 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.
Submit the completed form, including supporting materials, to CivilRightsEvaluation@hq.dhs.gov. This form clarifies the recipient's
civil rights obligations and related reporting requirements contained in the DHS Standard Terms and Conditions.
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.
Subrecipients are not required to complete and submit this form to DHS. However, subrecipients have the same obligations as their
primary recipients to comply with applicable civil rights requirements and should follow their primary recipient's instructions for
submitting civil rights information to those recipients.

Section 2: Organization Information
Organization Name:

Unique Entity Identifier:

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

Federal Award Identification Number:

Section 3: Civil Rights Requirements
As a condition of receipt of Federal financial assistance, the recipient is required 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, which prohibits discrimination based on race, color, or national origin (including

•
•

Section 504 of the Rehabilitation Act of 1973, which prohibits discrimination based on disability.

•
•

Age Discrimination Act of 1975, which prohibits discrimination based on age.

limited English proficiency).
Title IX of the Educations Amendments Act of 1972, which prohibits discrimination based on sex in education programs or
activities.
U.S. Department of Homeland Security regulation 6 C.F.R. Part 19, which prohibits discrimination based on religion in
social service programs.

DHS Form 3095 (8/17)

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Section 4: Required Information
1.

Provide the total number of complaints or lawsuits against the recipient during the past three (3) years alleging discrimination
on the basis of race, color or national origin (including limited English proficiency), sex, age, disability, religion, or alleging
retaliation. For each complaint or lawsuit, state the following:
a. Employment or non-employment related;
b. Basis (race; color; national origin, including limited English proficiency; sex; age; disability; religion); or alleging
retaliation; and
c. Status (pending, closed with findings, closed with no findings).
Additionally, if a court or administrative agency made a finding of discrimination in a non-employment complaint for the above
three (3) years, forward a copy of the complaint and findings to DHS.
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.

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.

3.

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

4.

Provide a copy of the recipient's nondiscrimination policy statement referencing the laws and regulations in Section 3.

5.

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

6.

Provide a copy of the recipient's plan to ensure compliance in subrecipient programs (only applies to state administering
agencies and other recipients that provide assistance to subrecipients). The plan should describe the process for conducting
reviews of subrecipients.

7.

Provide copies of the recipient's policy and procedures used to ensure nondiscrimination and equal opportunity for persons
with disabilities to participate in and benefit from the recipient's programs and services.

8.

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).

Section 5: Additional Information
Resources for recipients related to the above requirements: http://dhs.gov/resources-recipients-dhs-financial-assistance
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 3 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
DHS Form 3095 (8/17)

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