Form OMB 1190-0008 OMB 1190-0008 Complaint Form

COMPLAINT FORM

The purpose of this form is to assist you in filing a complaint with the Coordination and Review Section. 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, whether or not the form is used.

1.* State your name and address.

Name: _______________________________________________________

Address: _______________________________________________________

_____________________________ Zip ____________

Telephone No: Home: (_____)_______________ Work: (_____)_______________

2.* Person(s) discriminated against, if different from above:

Name: _______________________________________________________

Address: ______________________________ Zip___________

Telephone: Home:(_____)_______________ Work:(_____)_______________

Please explain your relationship to this person(s).

3.* Agency and department or program that discriminated:

Name: ________________________________________________________

Any individual if known: _____________________________________________

Address: _______________________________________________________

_____________________________ Zip ___________

OMB No. 1190-0008

Expires: 07/31/07

Telephone No:(____)_______________

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: ________________________________

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 No:(_____)_______________

7. If you have an attorney representing you concerning the

matters raised in this complaint, please provide the following:

Name: ____________________________________________

Address: _____________________________________________

_____________________________ Zip ____________

Telephone No: (_____)_______________

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 must generally 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.

10.* Please explain as clearly 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. The laws we enforce prohibit recipients of Department of Justice funds from intimidating or retaliating against anyone because he or she has either taken action or participated in 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 the circumstances below. Be sure to explain what actions you took which you

believe were the basis for the alleged retaliation.

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.)?

Yes ____ No ____

If so, do you remember the Complaint Number?

______________________________________

Against what agency and department or program was it filed?

______________________________________________

Address: ____________________________________________

________________________ Zip __________________

Telephone No: (____)_______________

Date of Filing: ____________ DOJ Agency:______________________

Briefly, what was the complaint about?

What was the result?

16. Have you filed or do you intend to file 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

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.

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

Coordination and Review 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: ________________________

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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