U.S. Department of Education
Office for Civil Rights
DISCRIMINATION COMPLAINT FORM

This form is not required to file a complaint with the Office for Civil Rights (OCR); however, the information requested on items 1 through 7 and on item 12 must be provided in writing, whether or not the form is used. Please type or print all information and use additional pages if more space is needed.


1. Name of person filing this complaint:
NAME (Mr./Ms.): ________________________________________
(Last) (First) (Middle)

ADDRESS: ________________________________________

CITY & STATE: ________________________________________
(Zip Code)

PHONE NO: ____________________________________(Home)
(Area Code) (Number)


____________________________________(Work)
(Area Code) (Number)


2. Name of person allegedly discriminated against (if other than person filing):
NAME (Mr./Ms.): ________________________________________
(Last) (First) (Middle)

ADDRESS: ________________________________________

CITY & STATE: ________________________________________
(Zip Code)

PHONE NO: ____________________________________(Home)
(Area Code) (Number)


____________________________________(Work)
(Area Code) (Number)




3. OCR engages in resolution activities on discrimination complaints against institutions and
agencies which receive funds from the U.S. Department of Education. It also engages in
such activities for certain public entities that are subject to the provisions of Title II of the
Americans with Disabilities Act (ADA). Please identify the institution or agency that
engaged in the alleged discrimination. If we cannot accept your complaint, we will attempt to
refer it to the appropriate agency and will notify you of that fact.


NAME OF INSTITUTION: _____________________________________
ADDRESS: __________________________________________________

CITY & STATE: ______________________________________________
(Zip Code)
DEPT/SCHOOL: ______________________________________________


Please indicate the relationship of the person identified in item 2 to the above institution:
student, employee or other (please specify) _____________________________


| Top of Page | Previous Section |

4. The regulations OCR enforces prohibit discrimination on the basis of race, color, national
origin, sex, disability, and/or age. Please indicate the basis or bases for the discrimination
alleged in this complaint:

For example:

Discrimination based on race: black;
Discrimination base on disability: learning disability.

______________________________________________________________

______________________________________________________________



5. Please describe the alleged discriminatory act(s). Please include the dates of the alleged
discrimination, the names of persons involved and, as available, the names of any persons
who witnessed the acts.

______________________________________________________________

______________________________________________________________

______________________________________________________________






6. Please state the facts which you believe indicate that the acts were discriminatory on the basis
or bases you specified in item 4.

______________________________________________________________

______________________________________________________________

______________________________________________________________



7. What is the most recent date that the alleged discrimination occurred?

_______________________________________________________________


If this date is more than 180 days ago, you may request a waiver of the filing requirement.
Please do so here and explain why you waited until now to file your complaint.

______________________________________________________________

______________________________________________________________

______________________________________________________________


8. Have you attempted to resolve the allegations contained in this complaint with the institution
through an internal grievance procedure?

YES_____ NO_____



If you answered yes, please describe the allegations in your grievance, identify the date you
filed your grievance, and tell us the status of the grievance. If possible, please provide us with
a copy of your grievance filed with the institution and any responses from the institution.


______________________________________________________________

______________________________________________________________

______________________________________________________________




| Top of Page | Previous Section |



9. If the allegations contained in this complaint have been filed with any other Federal, state or
local agency, or any Federal or state court, please give details and dates. We will determine
whether it is appropriate to engage in complaint resolution activities based upon the specific
allegations of your complaint and the actions taken by the other agency or court.


AGENCY OR COURT: __________________________________________

______________________________________________________________

______________________________________________________________

DATED FILED: _______________________________________________


CASE NUMBER OR REFERENCE: ______________________________

RESULTS OF INVESTIGATION/FINDINGS BY AGENCY OR COURT:

_____________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________


10. If we cannot reach you at your home or work, we would like to have the name and
telephone number of another person (relative or friend) who knows where and when
we can reach you. This information is not required, but it will be helpful to us.


NAME (Mr./Ms.): ________________________________________
(Last) (First) (Middle)

ADDRESS: ________________________________________

CITY & STATE: ________________________________________
(Zip Code)

PHONE NO: ____________________________________(Home)
(Area Code) (Number)

____________________________________(Work)
(Area Code) (Number)



11. OCR has an expedited complaint resolution process called Early Complaint Resolution
(ECR). In this process, we attempt to help the complainant and the institution reach an
agreement through mediation to settle the complaint. Both the complainant and the institution
must want to take part in the mediation. The complainant, the institution, or OCR may end
the ECR process at any time if it appears that an agreement cannot be reached. If this
happens, we will use other approaches to resolve the complaint allegations. One of the
primary benefits of ECR is that it may be possible to resolve your complaint quickly. More
information about the ECR process is contained in the enclosed document, "Information
About OCR's Complaint Resolution Procedures."

If OCR feels that mediation of your complaint is appropriate, are you interested in having
OCR mediate your complaint?


YES_____ NO_____


If you answered yes and OCR determines ECR may be appropriate, we will contact you
to discuss our ECR procedures in detail.

12. We cannot accept your complaint if it has not been signed. Please sign and date your
complaint below.
 

Please send us copies of any written materials or other documents which you think will help
us understand your complaint.

Please mail the completed Discrimination Complaint Form to: The U.S. Department of
Education, Office for Civil Rights, Regional Office in your area. Also, please enclose your
signed consent form(s) with the Discrimination Complaint Form. See "Information About
OCR's Complaint Resolution Procedures" for information about the consent forms. If you
have any questions about how to complete this form or properly file your complaint, please
call the appropriate regional office. Thank you.