Disability

Contact Us: Civil Rights and/or Civil Liberties Complaint Form

This form will assist you in filing a civil rights and/or civil liberties complaint with the Transportation Security Administration's (TSA) Office of Civil Rights and Liberties, Ombudsman and Traveler Engagement (CRL/OTE), regarding a TSA program, activity, or policy.

This form is not intended to be used for complaints by TSA employees regarding employment with TSA. If you are an employee of TSA please visit http://www.tsa.gov/what_we_do/civilrights/employees.shtm.

You are not required to use this form to file your civil rights or civil liberties complaint; an email or letter with similar information is sufficient. If you do not intend to use the online form, you can e-mail a complaint to: [email protected] or you may write CRL/OTE at the below address:

Disability and Multicultural Division
Office of Civil Rights & Liberties, Ombudsman and Traveler Engagement
701 South 12^th Street, TSA-6

Arlington, VA 20598-6033

Notes on Confidentiality and Anonymity:
1. If you would like to file an anonymous complaint, click here. Please not that if you file an anonymous complaint we may not be able to provide you with a response to your concerns.

2. Disclosure of the information you provide, including your identity, is on a "need-to-know" basis, and is discussed in the Privacy Statement at the end of this document.

If you have problems understanding this form, do not speak or write English, or have any other questions, please contact CRL/OTE by e-mail at [email protected]. CRL/OTE has access to translators and can communicate with you.

Please indicate preferred language for TSA to communicate with you.

COMPLAINT INFORMATION

* indicates the field is required

1) Information about the person who allegedly experienced a civil rights and/or civil liberties violation

*First Name:
*Last Name:
*Main Phone:
Work Phone:
Cell Phone:
*PO Box or Street Address:
*City:
*State:
*Zip:
*Email:

Check here if you are NOT the person that experienced the civil rights and/or civil liberties violation but are assisting him or her file this complaint.

2) Have you been authorized to file this complaint form on behalf of another individual?
By checking the box, I declare that I am authorized to file this complaint on behalf of myself or I have been legally authorized to file this complaint on behalf of the above-named individual.

If you are filing this claim on behalf of someone else, please provide your contact information.

*First Name:
*Last Name:
*Main Phone:
Work Phone:
Cell Phone:
*PO Box or Street Address:
*City:
*State:
*Zip:
*Email:
Names (or other information, e.g., agency):
* Relationship with Complainant
PO Box or Street Address:
City:
State or Country:
Zip:
Phone No.:
Email:

3) What is the basis of your allegation?
Check all that apply.

Race National Origin Ethnicity Gender/ Sex Speech Religion Profiling Association Disability Unreasonable search & seizure

Fifth Amendment- Due Process Immigration Status Other Constitutional Right or Liberty not listed

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4)* What happened?
Describe what occurred.Please be as specific as possible in describing the circumstances surrounding your complaint.

4a)* When did this happen? Please provide the date and approximate time of the
experience. If this has occurred more than once or is ongoing and you wish to
complain about multiple instances, please, list all dates of occurrence

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4b)* Where did this happen?
Please specify name of airport or other facility):

5) Who treated you unfairly?
Please provide a description of the individual(s) and/or the name and badge number of the individual(s) involved.

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6)List anyone else who may have seen or heard what happened.
(If you do not know their names, provide whatever details you can)

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7) Is there any other information you want us to know about or consider?

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8) Please read the following and check the corresponding box to signify your consent and authorization. You must check the box prior to submitting the form.

I declare under penalty of perjury under the laws of the United States of America that the civil rights and/or civil liberties complaint that I have filed with TSA is true and correct and I have read and agree with and to the terms outlined in this Form.

I will cooperate with Transportation Security Administration’s (TSA) complaint resolution activities undertaken on my behalf. I understand that my failure to cooperate with TSA may result in the closure of my complaint. I understand that the TSA may share the information I have provided as needed to resolve this complaint.

I understand that the Privacy Act of 1974, 5 U.S.C. §552a, and the Freedom of Information Act, 5 U.S.C. §552, govern the use of personal information submitted to all Federal agencies and their individual components, including the CRL/OTE.

To provide your Consent and Authorization, check the box below

On the next page, you will have a chance to review your information before submission. Keep a copy of this complaint for your records before submitting it.

PRA Statement

Authority: 6 U.S.C. § 345 and 42 U.S.C. § 2000ee-1

Purpose: This information will be used by the TSA to investigate possible violations of civil rights or civil liberties related to TSA employees, programs, or activities. Disclosure is voluntary, but the failure to provide information may impact the quality of the investigation. It is estimated that the total average burden per response associated with this collection is 5 minutes. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB number. The control assigned to this OMB collection is 1652- 0030 and expires XX/XX/XXXX.

Routine Uses: Information will be used by and may be disclosed to TSA personnel as needed for the investigation and any remedial action. If your complaint is more appropriately handled by a different federal office, we will refer it to that office. For further information, please see system of records notice DHS/ALL-029, Civil Rights and Civil Liberties Records, 75 Fed. Reg. 39266.

OMB 1652- 0030