DHS_CRCL_Civil Rights Complaint Form_8-1-22

DEPARTMENT OF HOMELAND SECURITY

CIVIL RIGHTS COMPLAINT
The purpose of this document is to assist you in filing a civil rights/civil liberties complaint with the Department of Homeland Security
(DHS) Office for Civil Rights and Civil Liberties (CRCL) regarding DHS programs and activities. This document is not intended to be
used for complaints about employment with DHS. You are not required to use this document to file a complaint; a letter with the
same information is sufficient. However, if you file a complaint by letter, you should include the same information that is requested
in this document. In general, providing as much information as possible to CRCL assists with investigating your allegations.
However, none of the fields on the form is required, and CRCL will review whatever information you provide.

CRCL Mission:
The DHS Office for Civil Rights and Civil Liberties (CRCL) supports the Department of Homeland Security as it secures the nation
while preserving individual liberty, fairness, and equality under the law. We investigate claims of civil rights and civil liberties abuses,
to help DHS improve protections and programs.
Do you have a DHS civil rights or civil liberties complaint? If you believe that DHS personnel or a DHS program or activity
has violated your rights, we want to hear from you. Fill out this document, or write us an email or letter.
This document is available in other languages at www.dhs.gov/file-civil-rights-complaint. Complaints are accepted in
languages other than English. If you do not speak or write English, CRCL has access to interpreters and translators and
can communicate with you in any language.
In connection with a DHS program, activity, or policy, have you experienced:
• Discrimination based on your race, ethnicity, national origin, religion, sex, sexual orientation, gender identity, or disability?
(Note: do not use this form to make a complaint about employment discrimination; see
www.dhs.gov/filing-equal-employment-opportunity-eeo-complaint)
• Denial of meaningful access to DHS or DHS-supported programs, activities, or services due to limited English proficiency?
• Violation of your rights while in immigration detention or as a subject of immigration enforcement?
• Discrimination or inappropriate questioning related to entry into the United States?
• Violation of your right to due process, such as your right to timely notice of charges or access to your lawyer?
• Violation of the Violence Against Women Act’s confidentiality requirements or immigration status-related confidentiality
requirements?
• Physical abuse or any other type of abuse inflicted upon you?
• Any other civil rights or civil liberties violation related to a DHS program or activity, including discrimination by an organization or
program that receives financial assistance from DHS?

Notes on Confidentiality and Anonymity:
A) You may remain anonymous by not filling in your name below. However, CRCL may not be able to investigate your complaint
unless you provide enough information to conduct an investigation.
B) 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 CHECK THE BOX BELOW, WE WILL NOT DISCLOSE YOUR IDENTITY TO
OTHER OFFICES, IN OR OUT OF DHS (unless it is necessary for investigation of criminal misconduct). Note, however, that
checking this box will in many situations make it very difficult or impossible for us to investigate the allegations you raise.
I do NOT want CRCL to disclose my name to other offices, and understand this decision will often make it impossible for
an investigation to take place.

Note Prohibition Against Retaliation:
Federal law forbids retaliation or reprisal by any Federal employee against a person who makes a complaint or discloses information
to CRCL. If you believe that you or someone else is a victim of such a reprisal, please contact CRCL immediately by email at
[email protected] or by phone at 866-644-8369, 866-644-8361 (TTY).

DHS Form XXX (7/22)

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COMPLAINT INFORMATION
1.

Information about the person who experienced the alleged civil rights/civil liberties violation (Fill in what you can)

Name:
First and Middle (Given Names)

Phone #:

Cell/Mobile:

Last (Family Name/Surname)

Home:

Work:

Mailing Address:
PO Box or Street address

City

State

Zip

Country (if outside the United States of America)

Date of Birth (month/day/year):

Email:

Alien Registration # (if you have one and it’s available):
Check here if you are in detention now.
Which detention facility?
Facility name

Facility address

Check here if you are represented by an attorney for the issues described in this complaint. If so, please provide the attorney’s
name and contact information:

2.

Are you filling in this complaint form on behalf of another person?

If yes, please provide your information below, and provide their information above. (Please note that you must submit written
consent signed by the person who experienced the alleged civil rights or civil liberties violation to allow CRCL to release information
to you.)
Name:
First and Middle (Given Names)

Last (Family Name/Surname)

Job Title (if any):
Organization (if any):
Phone #:

Cell/Mobile:

Home:

Work:

Email:
Mailing Address:
PO Box or Street address

City

State

Zip

Country (if outside the United States of America)

3.

What happened? (Describe your complaint. Give as much detail as possible.)

Continue on an additional page, if needed.
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When did this happen? If ongoing, please indicate when the problem began. (If it happened on more than one date, list all
dates):

Where did this happen?
Place (for example, name the detention facility, airport, or other location):
City:
4.

State or Country:
Who is this about?

An employee, contractor, officer or program of (check as many as apply):
Citizenship and Immigration Services (USCIS)
Customs and Border Protection (CBP)*

Not sure
Non-DHS employee working under the authority of DHS
(e.g., 287(g) officer) (specify):

Customs Officer
Border Patrol Agent
Federal Emergency Management Agency (FEMA)

Other (specify):

Immigration and Customs Enforcement (ICE)
Secret Service (USSS)
Transportation Security Administration (TSA)*
U.S. Coast Guard (USCG)
*If your complaint is about a screening incident at an airport, train station, or border crossing, you may also file a complaint with the
Department of Homeland Security’s Traveler Redress Inquiry Program (DHS TRIP). Go to: www.dhs.gov/trip.
5.

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

Name (or other information, e.g., agency):
Mailing Address:
PO Box or Street address

Phone #:

City

State

Zip

City

State

Zip

Email:

Name (or other information, e.g., agency):
Mailing Address:
PO Box or Street address

Phone #:

Email:
Continue on an additional page, if needed.

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6.

Have you contacted any other DHS component or other federal, state, or local government agency or court about this
complaint?
Yes:

Agency/Office/Court:

Date:

No
If so, has anyone responded to your complaint?

Yes

No

(If Yes, describe what has been done to respond to your complaint.)

7.

Is there any other information you want us to know or consider?
(If needed, continue on an additional page provided at the end of this form.)

Continue on an additional page, if needed.
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8.

If you are not proficient in English, please identify the language we should use to communicate with you.

Language:
9.

If you have problems understanding this form or any other question, contact CRCL:

Email:

[email protected]

Phone:

Local: 202-401-1474, or
Toll Free: 866-644-8360

TTY:

Local TTY: 202-401-0470, or
Toll Free TTY: 866-644-8361

Fax:

202-401-4708

10.

U.S. Postal Service:
Department of Homeland Security
Office for Civil Rights and Civil Liberties
Compliance Branch, Mail Stop #01902707
Martin Luther King Jr Ave SE
Washington, DC 20528-0190
Note: Because of security measures, it can take up to 4 weeks for us to
receive U.S. mail.

To submit this form by email, please save, attach, and send to [email protected]. Please attach or send
all information that supports your complaint, such as documents, photos, medical records, grievances, or witness
statements.

Submit copies, not originals; put your name and the date of this complaint on each document. (Fax to: 202-401-4708, or email scans
of your documents to [email protected], or mail to the address listed above.)
Date this form was completed:
Keep a copy of this complaint for your records.

Privacy Act Statement
Authority: 6 U.S.C. § 345 and 42 U.S.C. § 2000ee-1 authorizes the collection of this information.
Purpose: The Department of Homeland Security (DHS) will use this information to review and investigate complaints and
information from the public about possible violations of civil rights and/or civil liberties relating to DHS employees, programs, or
activities.
Routine Uses: This information may be disclosed to and used by personnel and contractors within DHS who have a need to know
the information in order to review your complaint. The DHS Office for Civil Rights and Civil Liberties (CRCL) may also share your
information as necessary with appropriate government agencies outside of DHS or with non-government entities to address your
complaint, or pursuant to its published Department of Homeland Security/ALL-029 Civil Rights and Civil Liberties Records System of
Records.
Disclosure: Furnishing this information to CRCL is voluntary; however, failure to furnish the requested information may delay or
prevent CRCL from adequately reviewing and investigating your complaint. If necessary, CRCL may also request additional
information from you in order to determine the appropriate manner to address your concerns.
To learn more about the Privacy Act, go to www.dhs.gov/privacy.

Paperwork Reduction Act
The public reporting burden to complete this information collection is estimated at 1 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and the completing and
reviewing the collected information. An agency may not conduct or sponsor, and a person is not required to respond to a collection
of information unless it displays a currently valid OMB control number and expiration date. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the DHS Office for
Civil Rights and Civil Liberties, [email protected], ATTN: PRA 1601-NEW.

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You may use the following pages to include additional information about your complaint if needed. Please specify which
number(s) above you are continuing.

DHS Form XXX (7/22)

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