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.

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) _____________________________

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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.
 

       ______________________________________________________________

        ______________________________________________________________

        ______________________________________________________________
 
 
 

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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)
 

         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.

 

__________________        _________________________________________
                (Date)                                                             (Signature)

         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.

I have read the Office for Civil Rights (OCR) document, "Information about OCR's Complaint Resolution Procedures," which includes information about OCR's Investigatory Uses of Personal Information.
 

I am aware that it is the policy of OCR to protect the identity of complainants who cooperate with OCR's investigations. However, I acknowledge that release of my identity to the institution, agency, or other entity named below maybe essential to the investigation and enforcement activities conducted by OCR. I give my consent in those limited circumstances when release is required for the processing of the complaint. I also assure OCR that I will cooperate with the complaint resolution activities undertaken on my complaint.
 

In addition, I acknowledge that under the Freedom of Information Act (FOIA) OCR may be required to disclose information gathered from me pursuant to this investigation. Although no guarantee of confidentiality has been given to me in exchange for information, I have not waived any right to privacy under FOIA that OCR may assert on my behalf.
 

I understand that the information I provide, as well as other information developed by the investigation, will be used to resolve my complaint against the institution, agency, or other entity named below. I understand that this information will be available to any persons within the U.S. Department of Education with a need to know its contents and may be used for program analysis, review, evaluation, and statistical purposes. However, should there be a need to disclose information from the complaint file for reasons other than those already stated, or pursuant to the Privacy Act or the Freedom of Information Act, my prior consent will be solicited.
 
 
 
 

__________________        _________________________________________
                (Date)                                                             (Signature)
 
 

                                     _________________________________________
                                                                               (Please Print or Type Name)
 
 
 
 
 

_______________________________
Name of the institution, agency, or other
entity against whom your complaint is lodged.
 

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Equal Employment Opportunity Commission

This organization deals with sexual harassment in employment settings. If you have experienced sexual harassment as a student, in conjunction with a part-time or full-time job with the university, you may file a complaint with the Equal Employment Opportunity Commission (EEOC). The statute of limitations for filing such complaints is 180 days from the last occurrence of harassment.
 

You can contact the EEEO at the address on phone numbers given below and request information about the appropriate regional office to which your complaint should be directed.
 

The Equal Employment Opportunity Commission
Office of Equal Employment Opportunity
1801 L. Street NW
Washington, D.C. 20507
Telephone: (800) 669-EEOC or (800) 800-3302 (TDD)
 

(4) State or Federal Court

As a victim of sexual harassment, your civil rights have been violated! You have the option of filing a state or federal lawsuit against the university and in some instances the individual harasser. In order to initiate a lawsuit, you will need an attorney.

Most cities and counties in the United States have a local BAR Association, which is a professional organization for attorneys. You can easily find their number in a phone book or ask Directory Assistance.

The BAR Association will provide you with information about local attorneys who specialize in civil rights and sexual harassment cases. You can then call those attorneys and inquire about their experience, interest in taking your case, fee structure, and references.