Not Available DL1-2014a-English

Complaint Information Form

DL 1-2014A (Rev 7/2015)

U.S. Department of Labor

Office of the Assistant Secretary for Administration and Management Civil Rights Center

OMB Control Number 1225-0077 Expiration Date: 04/30/2024

Please read the form carefully. Type or print your answers. Answer each question as completely as possible. If you cannot fit your whole answer in the space on this form, you may add more pages.

If a question or field has a star next to it, you must answer that question. You do not have to answer the other questions, but if you do, it will help us to process your complaint. If you do not know the answer to a question, put "not known" in the space for the answer. If the question does not apply to your case, put "n/a."

*1. Are you the complainant or a representative of the complainant? Please check the correct box.

Complainant

Representative

*2. Please give your name and the other information we ask you for on the lines below. If you are a representative, please give the complainant's name and contact information in this section, and your own name and contact information in section 2A.

*Complainant's Name

*Street Address

*City *State Zip Code

Telephone number(s) where we can reach you. (Do not give your work number if you don't want CRC to call you there.)

_{E-mail Address} Best time to contact you.

Name and contact information for someone we can contact if we cannot get in touch with you

2A. If you are the complainant's representative, please give your name and contact information in this section, and attach a letter or other document signed by the complainant, authorizing you to serve as his or her representative.

Representative's Name Representative's Organization (if any)

Street Address

City State Zip Code

Telephone number(s) where we can reach you. (Do not give your work number if you don't want the CRC to call you there.)

E-mail Address Best time to contact you.

For the rest of the questions on this form, if you are filing this complaint on behalf of someone else, "you" means that person (the complainant), not you personally. Please give the answers the complainant would give if they were filling out the form.

*3. This complaint is about something that happened to (Please check the appropriate box):

Only me

Me and other people

Other people, but not me

*4. Please give the name of the agency, organization, or business that you are complaining about. If you have any contact information for the agency, organization, or business, and/or if you know the name of the person(s) who you think discriminated against you, please give that information as well. If you need more space to give all of the information, please attach more pages to this form.

*Name of Agency, Organization, or Business _{Telephone Number(s)}

Street or Mailing Address E-mail Address

Name of Person You Think Discriminated

Job Title

E-mail Address

*5. What program was involved in the discrimination you are complaining about? If you do not know the name of the program, and your complaint does not involve an American Job Center or a state or local government agency, please check "Do not know."

Workforce Innovation and Opportunity Act Program

Job Corps Program Unemployment Insurance

Employment Service or Job Service Trade Assistance Act Program

Older Workers Program (Senior Community Service Employment Program) Indian/Native American Program

Migrant and Seasonal Farm Workers Program Vocational Rehabilitation

Other (what program? ⁾

American Job Center State or Local Government Do not know

*6. What do you think was the basis (reason) for the alleged discrimination? Please check the boxes next to all of the bases (reasons) you think were involved in the discrimination, and answer any other questions that go along with that box.

In the next question, you will be asked to explain why you checked each box.

B ecause of my National Origin (Please answer questions below.)

A re you Hispanic or Latino? Yes No

What is your national origin (the country from which you, your parents, your grandparents, or your earlier ancestors came)? _________________________________

B ecause of my Limited English Proficiency (What is the language in which you feel most comfortable communicating? For example, Spanish, Croatian, Cambodian) __________________________________

Because of my Race (Please answer questions below).

What is your race? Please check all that apply.

White or Caucasian

B lack or African American

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Asian

Because of my Color (What is your color? __________________)

Because of my Religion (What is your religion? __________________)

Because of my Age (What is your date of birth? __________________)

Because of my Political Affiliation or Political Belief (What is your political affiliation or political belief? __________________)

B ecause of my Sex (What is your sex? __________________)

B ecause of my Gender Identity (What is your gender identity? __________________)

B ecause of my Sexual Orientation (What is your sexual orientation? __________________)

B ecause of my Pregnancy

B ecause of my Disability (Please check one of the following three boxes.)

I have a disability (which may be active or inactive right now)

(What is your disability? ____________________________)

I have a record of a disability

(What was your past disability? _____________________________)

I do not have a disability, but the organization or program treats me as if I am disabled.

Because of my Citizenship (What is your citizenship? _____________________)

B ecause of my participation in a program that receives Federal financial assistance (Name the program: ________________)

I was Retaliated Against (Retaliation) because I complained about discrimination, or because I gave a statement or was involved in some other way with someone else's discrimination complaint.

*7. For each of the bases (reasons for discrimination) you checked above, please explain what happened, how you were (or someone else was) harmed by what happened, and how or why you think what happened was because of the basis you checked. For example, if you checked "Because of my Race," list the facts you think explain how or why you think what happened was because of the race of the persons who were harmed. If you do not explain why you checked a particular basis, we may reject that part of your complaint.

If other persons or groups were treated differently from you (or the other people who you think were discriminated against), please describe who was treated differently, how their treatment was different, and how the different treatment harmed you (or the other people you think were discriminated against). Please be specific and brief. Give the name(s) of and contact information for any of the people involved, if you can.

If your answer does not fit in the space below, please use more pages of paper to finish your answer, and attach those pages to this form.

*8. On what date(s) did the alleged discrimination take place?

8A. Date of the first action:

8B. Date of most recent action:

8C. If the date of the most recent action was more than 180 days ago, please explain why you did not file a complaint before now.

9. Please list below any other people (witnesses, coworkers, supervisors, or others) whom you have not already named and whom we should contact for information about your complaint. Attach additional pages if you need more space for this information.

Person's Name Relationship to case (witness, coworker, etc.) Best time to contact this person.

Telephone number(s) and/or e-mail address(es) where we can contact this person.

9. Have you filed a written complaint with anyone else, such as the Equal Employment Opportunity Commission (EEOC), or State Equal Opportunity Officer, about the same events or actions you describe on this Complaint Information Form? If yes, please answer these questions, as best you can, about each agency, department, organization, or business where you filed a written complaint (using additional pages if necessary):

^{10A. Where and when did you file your first written complaint?} Date Filed

Name of Specific Office or Agency, Department, Organization, or Business Phone Number E-mail Address

Mailing or Street Address City State Zip Code

Name and Contact Information for person working on your complaint, if known.

10B. Has the place where you filed your first written complaint given you a final decision about the complaint? 10C. If yes, what was the date of the final decision? Was the decision in writing?

Yes No

Yes No

Include copies of written decisions, dismissals, or Right-to-Sue Letters, or other written responses to your complaint that you have received.

9. What remedies are you asking for? For example, getting benefits or training you did not receive, changes in policies, etc. PLEASE NOTE: The laws that CRC enforces do not allow for punitive damages. Money may only be awarded to compensate victims of discrimination for actual losses.

*12. Please sign and date this form in the space below that applies to you. You must also read the notice on the next page entitled "How We Use Personal Information," and sign and date the consent form. CRC cannot accept a complaint for investigation unless both the Complaint Information Form and the Consent Form have been signed.

^{Signature of Complainant} Date

^{Signature of Complainant's Representative} Date Please mail, email, or fax a complaint to:

Mail: Director

Civil Rights Center

U.S. Department of Labor

200 Constitution Avenue, N.W. Room N-4123

Washington, DC 20210

Fax: (202) 693-6505

Email: [email protected]

Persons are not required to respond to a collection of information unless it displays a currently valid OMB control number. Completing this form is voluntary; however, answers to the starred questions and fields must be provided in order for the Department of Labor's Civil Rights Center (CRC) to accept your discrimination complaint. CRC will use the information to process, and where appropriate to investigate, your complaint. The estimated average time to complete this form is 60 minutes. 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.

U.S. Department of Labor

Office of the Assistant Secretary for Administration and Management Civil Rights Center

HOW WE USE PERSONAL INFORMATION

Two Federal laws govern personal information that is given to Federal agencies such as the Civil Rights Center (CRC). These two laws are the Privacy Act of 1974 (5 U.S.C. 552a) and the Freedom of Information Act (5 U.S.C. 552), known as "FOIA." This Notice describes how each of these laws applies to information connected with your complaint. Please read the Notice, sign the Consent Form on the next page, and give the Consent Form to CRC with your Complaint Information Form.

The PRIVACY ACT protects you from misuse of personal information that the Federal government has about you. This law applies to records that the Federal government keeps that can be located by a person's name, social security number, or other personal identification system. Anyone who submits personal information to CRC in connection with a discrimination complaint should know the following:

1. CRC enforces civil rights laws that cover State and local government agencies, programs conducted by DOL, recipients of financial assistance from DOL, and certain recipients of financial assistance from other Federal departments and agencies ("covered entities"). CRC has the authority to investigate and make determinations on complaints alleging that a covered entity has discriminated on the basis of race, color, national origin, age, disability, sex/gender, religion, political affiliation or belief, citizenship, and participation in a program or activity that receives financial assistance under Title I of the Workforce Investment Act of 1998 (WIA) and/or Title I of the Workforce Innovation and Opportunity Act of 2014. CRC is also authorized to conduct reviews of covered entities to evaluate whether they are complying with the civil rights laws that CRC enforces.

2. Information that CRC collects is analyzed by authorized personnel within the agency. This information may include personnel records or other personal information. CRC 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. CRC 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.)

3. 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 DOL's regulation at 29 C.F.R. Part 71, CRC 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 exceptions is when release is required under the Freedom of Information Act. (See below.)

4. No law requires a complainant to give personal information to CRC, and no sanctions will be imposed on complainants or other individuals who deny CRC's request. However, if CRC fails to obtain information needed to investigate the ability of allegations of discrimination, it may be necessary to close the investigation.

5. 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 CRC to exercise authority to exempt systems of records only in compelling cases. CRC may deny a complainant access to the files compiled during the agency investigation of his or her civil rights complaint against a covered entity. Complaint files are exempt in order to aid negotiations between covered entities and CRC in resolving civil rights issues and to encourage covered entities to furnish information essential to the investigation.

6. CRC 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 covered entity that violates the laws, or unless such information is required to be disclosed under FOIA or the Privacy Act. CRC 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.

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. CRC must honor requests under the Freedom of Information Act, with some exceptions. CRC generally is not required to release documents during an investigation or enforcement proceedings if the release could have an adverse effect on 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."

PLEASE READ THE CONSENT FORM ON THE NEXT PAGE, SIGN EITHER SECTION A OR SECTION B, AND GIVE THE SIGNED FORM TO THE CIVIL RIGHTS CENTER WITH YOUR SIGNED, COMPLETED COMPLAINT INFORMATION FORM.

CONSENT FORM

I have read the Civil Rights Center's notice entitled "How We Use Personal Information." I understand that the following conditions apply to personal information I disclose to CRC in connection with my complaint:

CRC may need to disclose my identity to staff of the agency, organization, or business I named in my complaint, in order to gather evidence or verify facts related to the complaint, or to complete enforcement proceedings against the agency, organization, or business;

I do not have to reveal any personal information to CRC, but CRC may close my case if it cannot get the information it needs to process or fully investigate my complaint;

I may request a copy of any of my personal information that CRC keeps in my complaint file; and

Under certain conditions, CRC may be required by the Freedom of Information Act or other laws to disclose my personal information to others.

SECTION A

YES, CRC MAY DISCLOSE MY IDENTITY IF NECESSARY TO FULLY INVESTIGATE MY COMPLAINT. I have

read and understand the notice "How We Use Personal Information," and I give consent for CRC to disclose my identity to the respondent, if necessary to fully investigate my complaint.

^(Signature) (Date)

SECTION B

NO, CRC MAY NOT DISCLOSE MY IDENTITY TO THE RESPONDENT, EVEN IF NECESSARY TO FULLY

INVESTIGATE MY COMPLAINT. I have read and understand the notice "How We Use Personal Information," and I understand that CRC may close my case if it cannot get the information it needs to fully investigate my complaint without disclosing my identity to the respondent. Nonetheless, I do not give consent for CRC to disclose my identity to the respondent during the investigation of my complaint.

^(Signature) (Date)

FOR DOL USE ONLY

^{CIF received by the CRC} Accepted Not Accepted Case Number

By Date

-1-

DL1-2014A

Revised July 2015