Consent Form - English

U.S. Department of Justice
Civil Rights Division

"Coorilination and Review Section

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 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.
,:t'-:"~

The laws and regulations which govern DOJ's compliance and enforcement authority
: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 which is maintained in
DOJ's investigative files may be exempt from disclosure under the Privacy Act or under the
Freedom of Information Act if 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 Department of Justice (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
(0, 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
DOJ also is authorized to
assistance.
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. (See below)

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.
- DOJ does not reveal the names or
other identifying information about an
individual unless it is necessary for the
completion of an investigation or for
enforcement activities against a recipient
that violates the laws, or unless such
information is required to be disclosed
under FOIA or the Privacy Act. DOJ will
keep the identity of complainants
confidential except to the extent necessary
to carry out the purposes of the civil rights
laws, or unless disclosure is required under
FOIA, the Privacy Act, or otherwise
required by law.

- Personal information will be used
only for the specific purpose for which it
was submitted, that is, for authorized civil
rights
compliance and
enforcement
activities. Except in the instances defined
in DOJ's regulation at 28 C.F.R. Part 16,
DOJ will not release the information to any
other agency or individual unless the person
who supplied the information submits a
written consent. One of these excepti()ns
is when release is required under the
Freedom of Information Act. (See below)

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."

- 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

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U.S. Department of Justice
Civil Rights Division
Coordi1U1lion and Review Section

COMPLAINANT CONSENT/RELEASE FORM
Your Name: _____________________________________________________________
Address: ____________________________________

Complaint number(s): (if known) _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __

Please read the information be/ow, 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, which 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
D'·CONSENT - 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.
CONSENT 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
'-Mvestigation of my complaint. I understand this is likely to impede the investigation of my
complaint and may result in the closure of the investigation.
D

SIGNATURE

DATE