OMB Number 1190-00 Complaint and Consent Form

U.S. Department of Justice
Civil Rights Division
Federal Coordination and Compliance Section
950 Pennsylvania Ave., NW - NWB
Washington, DC 20530

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 Department of Justice (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.
- Title VI of the Civil Rights Act of 1964, 42 U.S.C. §§ 2000d – 2000d7, and its
implementing regulations, 28 C.F.R. § 42.401 et seq., govern DOJ’s compliance and
enforcement authority. These provisions 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 maintained in DOJ’s
investigative files may be exempt from disclosure under the Privacy Act or under the Freedom
of Information Act if the 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 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 to
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 assistance.
DOJ also is authorized to conduct reviews of
federally funded recipients to assess their
compliance with civil rights laws.

U.S. Department of Justice
Civil Rights Division
Federal Coordination and Compliance Section
950 Pennsylvania Ave, NW
Washington, DC 20530

- 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.
- The personal information will be used
primarily for DOJ’s authorized civil rights
compliance and enforcement activities. FCS
will not disclose your name or other
identifying information about you unless it
is necessary for enforcement activities
against an entity alleged to have violated
federal law, or unless such information is
required to be disclosed under the Freedom
of Information Act, 5 U.S.C. § 552, or
disclosure is allowed through the publication
of a routine use in accordance with the
Privacy Act of 1974, 5 U.S.C. § 552a.
http://edocket.access.gpo.gov/2003/pdf/0320342.pdf To further the Department’s
enforcement activities, information FCS has
about you may be given to: appropriate
federal, state, or local agencies: Members of
Congress or staff; volunteer student workers
within the Department of Justice so that they
may perform their duties; the news media
when release is made consistent with the
Freedom of Information Act and 28 C.F.R.
§ 40.2; and the National Archives and

Records Administration and General
Services Administration to perform records
management inspection functions in
accordance with their legal responsibilities.
- 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 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.
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.”

U.S. Department of Justice
Civil Rights Division
Federal Coordination and Compliance Section - NWB
950 Pennsylvania Ave, NW
Washington, DC 20530

COMPLAINT FORM
The purpose of this form is to assist you in filing a complaint with the Federal Coordination and
Compliance Section (FCS). 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 if you submit something other than this form.
1.* Your name and address.
Name: ________________________________________________________________________
Address: _______________________________________________________________________
_____________________________________________________________ Zip ______________
Telephone: Home: (_____)___________________ Work or Cell: (_____)___________________
2.* Person(s) discriminated against, if different from above:
Name: _______________________________________________________________________
Address: _______________________________________________________________________
_____________________________________________________________Zip ______________
Telephone: Home: (_____)___________________ Work or Cell: (_____)__________________
Please explain your relationship to this person(s).
______________________________________________________________________________
3.* Agency and department or program that discriminated:
Name: _______________________________________________________________________
Address: _______________________________________________________________________
_____________________________________________________________ Zip ______________
Telephone: Home: (_____)___________________ Work or Cell: (_____)___________________
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: __________________________________________
OMB No. 1190-0008
Expires: 04/30/2014

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: Home:(_____)_________________ Work or Cell: (_____)__________________
7. If you have an attorney representing you concerning the matters raised in this complaint,
please provide the following:
Name: _______________________________________________________________________
Address: _____________________________________________________________________
____________________________________________________________Zip______________
Telephone: Home: (_____)__________________Work or Cell: (_____)___________________
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 generally must 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 and FCS will evaluate the explanation
and decide if a waiver is appropriate.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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10.* Please explain, as clearly and neatly 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. Title VI of the Civil Rights Acts of 1964, 42 U.S.C. §§ 2000d – 2000d7 and the nondiscrimination section of the Omnibus Crime Control and Safe Streets Act of 1968, 28 U.S.C.
§ 3789d(c), prohibit recipients of Department of Justice funds from intimidating or retaliating
against anyone because he or she has either taken action or participated in an 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, as clearly and neatly as possible, the
circumstances below. Be sure to explain what actions you took which you believe were the basis
for the alleged retaliation.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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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.) or other Federal agencies?
Yes ____ No ____
If so, do you remember the Complaint Number?
_____________________________________________________
What agency and department or program was it filed with?
______________________________________________________________________________
Address: ______________________________________________________________________
_______________________________________________________Zip ___________________
Telephone No: (____)_______________
Date of Filing: ____________________ Filed Against:_________________________________
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Briefly, what was the complaint about?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
What was the result?
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
16. Have you filed 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
Other _______________________________

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.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

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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
Federal Coordination and Compliance 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:
_______________________________________

Note: 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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U.S. Department of Justice
Civil Rights Division
Federal Coordination and Compliance Section
950 Pennsylvania Ave, NW
Washington, DC 20530

COMPLAINANT CONSENT/RELEASE FORM
Your Name:_________________________________________________________________________
Address:____________________________________________________________________________
____________________________________________________________________________
Complaint number(s): (if known) ________________________________________________________

Please read the information below, 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, that 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
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 investigation of my
complaint. I understand this is likely to impede the investigation of my complaint and may result in the
closure of the investigation.

______________________________________________
SIGNATURE

________________________
DATE