DHS Form 3095 Civil Rights Evaluation Tool

OMB Control No. 1601-0024
Expiration Date 08/31/2024

DEPARTMENT OF HOMELAND SECURITY

CIVIL RIGHTS EVALUATION TOOL
Section 1: Instructions
Recipients (as defined in 2 C.F.R. Part 200 and including recipients acting as pass-through entities) of Federal financial assistance
from the U.S. Department of Homeland Security (DHS) or one of its awarding component agencies must complete this tool within
thirty (30) days of receipt of the Notice of Award for the first award under which this term applies. Recipients of multiple awards of
DHS financial assistance should only submit one completed tool for their organization, not per award.
Recipients should submit the completed tool, including supporting materials, to CivilRightsEvaluation@hq.dhs.gov. This tool clarifies
the civil rights obligations and related reporting requirements contained in the DHS Standard Terms and Conditions.
Subsequent submissions: After the initial submission, recipients are required to complete the tool once every two (2) years if they
have an active award, not every time an award is made. After the initial submission, recipients are only required to submit updates. If
there are no updates since the initial submission, the recipient can indicate “no change” for each item as applicable to satisfy the
biyearly requirement. Recipients should not re-submit information previously submitted. The due date for submitting updates is
calculated from two (2) years from the date the recipient last submitted the tool to DHS. DHS will send an email reminder to the
contact person identified in Section 2 prior to the due date for the biyearly update.
Subrecipients: Subrecipients are not required to complete and submit this tool to DHS. However, subrecipients have the same
obligations as pass-through entities and recipients to comply with applicable civil rights requirements and should follow their passthrough entities' instructions for submitting civil rights information to those entities.
Extensions: The DHS Office for Civil Rights and Civil Liberties will consider, in its discretion, granting an extension if the recipient
identifies steps and a timeline for completing the tool. Recipients should request extensions by emailing the request to
CivilRightsEvaluation@hq.dhs.gov prior to expiration of the 30-day deadline.

Section 2: Organization Information
Organization Name:

Unique Entity Number

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
limited English proficiency).

•
•

Section 504 of the Rehabilitation Act of 1973, which prohibits discrimination based on disability.
Title IX of the Education Amendments Act of 1972, which prohibits discrimination based on sex in education programs or
activities.

•
•

Age Discrimination Act of 1975, which prohibits discrimination based on age.
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 (2/23)

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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: CivilRightsEvaluation@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 (2/23)

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