FCS Complaint and Consent Form

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

1190-0008_FCS_Complaint_Consent_Form_112216

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

OMB: 1190-0008

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NOTICE ABOUT INVESTIGATORY USES

OF PERSONAL INFORMATION

NOTICE OF COMPLAINANT AND INTERVIEWEE RIGHTS AND PRIVILEGES

Complainants and individuals who cooperate in an investigation, proceeding, or hearing conducted by Department of Justice (DOJ) are afforded certain rights and protections. This brief description will provide you with an overview of these rights and protections.

- A recipient may not force its employees to be represented by the recipient’s counsel nor may it intimidate, threaten, coerce or discriminate against any employee who refuses to reveal to the recipient the content of an interview. An employee does, however, have the right to representation during an interview with DOJ. The representative may be the recipient’s counsel, the employee’s private counsel, or anyone else the interviewee authorizes to be present.

- Title VI of the Civil Rights Act of 1964, 42 U.S.C. §§ 2000d – 2000d7, and its implementing regulations, 28 C.F.R. § 42.401 et seq., govern DOJ’s compliance and enforcement authority. These provisions provide that no recipient or other person shall intimidate, threaten, coerce, or discriminate against any individual because he/she has made a complaint, testified, assisted, or participated in any manner in an investigation, proceeding, or hearing conducted under DOJ’s jurisdiction, or has asserted rights protected by statutes DOJ enforces.

- Information obtained from the complainant or other individual maintained in DOJ’s investigative files may be exempt from disclosure under the Privacy Act or under the Freedom of Information Act if the release of such information would constitute an unwarranted invasion of personal privacy

There are two laws governing personal information submitted to any federal agency, including the DOJ: The Privacy Act of 1974 (5 U.S.C. § 552a), and the Freedom of Information Act (5 U.S.C. § 552).

THE PRIVACY ACT protects individuals from misuse of personal information held by the federal government. The law applies to records that are kept and that can be located by the individual’s name or social security number or other personal identification system. Persons who submit information to the government should know that:

- DOJ is required to investigate complaints of discrimination on the basis of race, color, national origin, sex, disability, age, and, in some instances, religion against recipients of Federal financial assistance. DOJ also is authorized to conduct reviews of federally funded recipients to assess their compliance with civil rights laws.

- Information that DOJ collects is analyzed by authorized personnel within the agency. This information may include personnel records or other personal information. DOJ staff may need to reveal certain information to persons outside the agency in the course of verifying facts or gathering new facts to develop a basis for making a civil rights compliance determination. Such details could include the physical condition or age of a complainant. DOJ also may be required to reveal certain information to any individual who requests it under the provisions of the Freedom of Information Act.

- The personal information will be used primarily for DOJ’s authorized civil rights compliance and enforcement activities. FCS will not disclose your name or other identifying information about you unless it is necessary for enforcement activities against an entity alleged to have violated federal law, or unless such information is required to be disclosed under the Freedom of Information Act, 5 U.S.C. § 552, or disclosure is allowed through the publication of a routine use in accordance with the Privacy Act of 1974, 5 U.S.C. § 552a. http://edocket.access.gpo.gov/2003/pdf/03-20342.pdf To further the Department’s enforcement activities, information FCS has about you may be given to: appropriate federal, state, or local agencies: Members of Congress or staff; volunteer student workers within the Department of Justice so that they may perform their duties; the news media when release is made consistent with the Freedom of Information Act and 28 C.F.R. § 40.2; and the National Archives and Records Administration and General Services Administration to perform records management inspection functions in accordance with their legal responsibilities.

- No law requires a complainant to give personal information to DOJ, and no sanctions will be imposed on complainants or other individuals who deny DOJ’s request. However, if DOJ fails to obtain information needed to investigate allegations of discrimination, it may be necessary to close the investigation.

- The Privacy Act permits certain types of systems of records to be exempt from some of its requirements, including the access provisions. It is the policy of DOJ to exercise authority to exempt systems of records only in compelling cases. DOJ may deny a complainant access to the files compiled during the agency investigation of his or her civil rights complaint against a recipient of federal financial assistance. Complaint files are exempt in order to aid negotiations between recipients and DOJ in resolving civil rights issues and to encourage recipients to furnish information essential to the investigation.

THE FREEDOM OF INFORMATION ACT gives the public access to certain files and records of the federal government. Individuals can obtain items from many categories of records of the government -- not just materials that apply to them personally. DOJ must honor requests under the Freedom of Information Act, with some exceptions. DOJ generally is not required to release documents during an investigation or enforcement proceedings if the release could have an adverse effect on the ability of the agency to do its job. Also, any Federal agency may refuse a request for records compiled for law enforcement purposes if their release could be an “unwarranted invasion of privacy” of an individual. Requests for other records, such as personnel and medical files, may be denied where the disclosure would be a “clearly unwarranted invasion of privacy.”

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U.S. Department of Justice

Civil Rights Division

Federal Coordination and Compliance Section

950 Pennsylvania Ave, NW

Washington, DC 20530

COMPLAINT FORM

The purpose of this form is to assist you in filing a complaint with the Federal Coordination and

Compliance Section (FCS). 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 if you submit something other than this form.

1.* 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: __________________________________________

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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 generally must 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 and FCS will evaluate the explanation

and decide if a waiver is appropriate.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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10.* Please explain, as clearly and neatly 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. Title VI of the Civil Rights Acts of 1964, 42 U.S.C. §§ 2000d – 2000d7 and the nondiscrimination section of the Omnibus Crime Control and Safe Streets Act of 1968, 28 U.S.C.§ 3789d(c), prohibit recipients of Department of Justice funds from intimidating or retaliating against anyone because he or she has either taken action or participated in an 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, as clearly and neatly as possible, the circumstances below. Be sure to explain what actions you took which you believe were the basis for the alleged retaliation.

_____________________________________________________________________________

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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.) or other Federal agencies?

Yes ____ No ____

If so, do you remember the Complaint Number?

_____________________________________________________

What agency and department or program was it filed with?

______________________________________________________________________________

Address: ______________________________________________________________________

_______________________________________________________Zip ___________________

Telephone No: (____)_______________

Date of Filing: ____________________ Filed Against:_________________________________

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Briefly, what was the complaint about?

_____________________________________________________________________________

What was the result?

_____________________________________________________________________________

16. Have you filed 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

_____ Other _______________________________

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.

_____________________________________________________________________________

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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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U.S. Department of Justice

Civil Rights Division

Federal Coordination and Compliance Section

950 Pennsylvania Ave, NW

Washington, DC 20530

COMPLAINANT CONSENT/RELEASE FORM

Your Name:_________________________________________________________________________

Address:____________________________________________________________________________

____________________________________________________________________________

Complaint number(s): (if known) ________________________________________________________

Please read the information below, check the appropriate box, and sign this form.

I have read the Notice of Investigatory Uses of Personal Information by the Department of Justice (DOJ). As a complainant, I understand that in the course of an investigation it may become necessary for DOJ to reveal my identity to persons at the organization or institution under investigation. I am also aware of the obligations of DOJ to honor requests under the Freedom of Information Act. I understand that it may be necessary for DOJ to disclose information, including personally identifying details, that it has gathered as a part of its investigation of my complaint. In addition, I understand that as a complainant I am protected by DOJ’s regulations from intimidation or retaliation for having taken action or participated in action to secure rights protected by nondiscrimination statutes enforced by DOJ.

CONSENT/RELEASE

C ONSENT - I have read and understand the above information and authorize DOJ to reveal my identity to persons at the organization or institution under investigation. I hereby authorize the Department of Justice (DOJ) to receive material and information about me pertinent to the investigation of my complaint. This release includes, but is not limited to, personal records and medical records. I understand that the material and information will be used for authorized civil rights compliance and enforcement activities. I further understand that I am not required to authorize this release, and do so voluntarily.

C ONSENT DENIED - I have read and understand the above information and do not want

DOJ to reveal my identity to the organization or institution under investigation, or to review, receive copies of, or discuss material and information about me, pertinent to the investigation of my complaint. I understand this is likely to impede the investigation of my complaint and may result in the closure of the investigation.

______________________________________________ ________________________

SIGNATURE DATE

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File Modified	2016-11-23
File Created	2016-11-23