Sample Discrimination Complaint Form

OMB Control Number 1225-0077

Sample Discrimination Complaint Form

Persons are not required to respond to a collection of information unless it displays a currently valid OMB control number. Pursuant to 29 CFR §§ 37.70-37.71 and 38.69, a complainant may file a written complaint with either the recipient or the U.S. Department of Labor, Civil Rights Center’s Director. This sample discrimination complaint form provides a template that recipients may use to collect information from complainants that file complaints of discrimination. The average estimated response time to complete this form is 60 minutes for each complaint entry. Send comments regarding this estimate or any other aspects of this collection of information to the U.S. Department of Labor, Office of the Assistant Secretary for Administration and Management, Civil Rights Center, Room N-4123, Washington, D.C. 20210. Please reference OMB control number 1225-0077, expiration date TO BE UPDATED.

SAMPLE: COMPLAINT INFORMATION FORM

It is against the law for <Agency>, as a recipient of financial assistance under Title I of the Workforce Investment Act (WIA) and/or the Workforce Innovation and Opportunity Act (WIOA), to discriminate on the bases of race, color, religion, sex, national origin, age, disability, political affiliation of belief. It is also against the law for <Agency> to discriminate against any beneficiary of Federally financially assisted programs on the basis of the beneficiary's citizenship/ status as a lawfully admitted immigrant authorized to work in the United States, or his or her participation in any WIA/WIOA Title I financially assisted program or activity. See regulations implementing WIA at 29 CFR part 37 and WIOA at 29 CFR part 38.

If you think that you have, or someone else has, been subjected to discrimination by <Agency> on one of the bases listed above, you may file a complaint within 180 days from the date of the alleged violation with either the <Agency> or the U.S. Department of Labor's Civil Rights Center (CRC). If you have missed this deadline and think you have good cause for filing late, you must explain the circumstances and request an extension from the Director of CRC at the address listed below. The Director will determine whether you have proven good cause for an extension and notify you of his/her determination.

To file a complaint, you may use this Complaint Information Form, or send the information listed on this form, in writing, either to <agency> or CRC. To file the complaint with <agency>, send it to <provide address for complaint filing at recipient level>. To file a complaint with CRC, send it to Director, Civil Rights Center, U.S. Department of Labor, 200 Constitution Ave NW, Room N-4123, Washington, DC 20210. You may obtain a CRC complaint form electronically through CRC's website at http://www.dol.gov/oasam/programs/crc/complaint.htm

Complainant Information Mailing Address:
Home Phone Number: Work Phone Number: Email Address:
Please provide the name and address of the person or organization that you believe discriminated against you or someone else. If you believe that someone else was discriminated against, identify that person or group of people to the best of your ability.
Explain as briefly and clearly as possible what happened and why you believe discrimination took place. Please give the name and contact information for any person that witnessed the events you described above. Also attach any written material that relates to the events you are describing.
Please check the box or boxes that you think best represents the reason why you believe you were, or someone else was, discriminated against. If you are filing a complaint because you believe someone else was discriminated against, and you do not have the exact information about that other person or group (such as their exact date of birth, race, national origin, or type of disability), then provide the best information that you can. For more information, see the WIA nondiscrimination regulations at 29 CFR part 37 and the WIOA nondiscrimination regulations at 29 CFR part 38.
Top of Form Race: Specify _____________________ Bottom of Form Top of Form Color: Specify ____________________ Bottom of Form Top of Form Religion: Specify __________________ Bottom of Form Top of Form National Origin: Specify ____________ Bottom of Form Top of Form Sex: Specify _________________________ Bottom of Form Top of Form Other: Specify _____________________ Bottom of Form	Top of Form Age: Specify Date of Birth ___________ Bottom of Form Top of Form Disability: Specify _________________ Bottom of Form Top of Form Political Affiliation: Specify__________ Bottom of Form Top of Form Citizenship: Specify ________________ Bottom of Form Top of Form Reprisal/Retaliation _______________Bottom of Form
Please explain the remedy that you are seeking.
Signature: _____________________________	Date: ____________________________

Disclaimer: Content provided in this toolkit does not create new legal obligations, and is not a substitute for the U.S. Code, Code of Federal Regulations, and Federal Register, which are the official sources for applicable statutes, regulations, notices, and other relevant documents.