Office for Civil Rights Discrimination Complaint Form

Before completing this form, please read the information describing its use:
http://www.ed.gov/about/offices/list/ocr/complaintintro.html

required fields

1. Enter information about yourself

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Best Time to Call You:

Primary Phone Number:

Alternative Phone Number:

Your Email Address:

2. Who else can we call if we cannot reach you?

Contact's Name:

Daytime Phone Number:

Relationship to you:

3. Who was discriminated against?

Yourself?

Someone else?

If someone other than yourself please include:

Injured Person's Name:

Daytime Phone Number:

Evening Phone Number:

Relationship to You
(eg. son or daughter)

Injured Person's Address:

City:

State:

Zip Code:

If the person discriminated against is age 18 or older, we will need that person's signature before we can proceed with this complaint. If the person is a minor, and you do not have legal authority to file a complaint on the student's behalf, the signature of the child's parent or legal guardian is required.

4. What institution discriminated?

OCR's laws cover educational institutions such as school districts, colleges and universities, public libraries and state vocational rehabilitation agencies.

Institution Name:

Address:

City:

State:

Zip Code:

School or department involved:

5. Have you tried to resolve the complaint through the institution's grievance process, due process hearing, or with another agency?

Yes

6. Describe the discrimination

OCR enforces regulations that prohibit discrimination on the basis of race, color, national origin; sex; disability; and/or age.

On what basis were you discriminated against?

(You may select more than one.)

race or color

national origin

Includes discrimination, including harassment, because you and/or another individual are, for example, Jewish, Muslim, Arab, Hindu, or Sikh; or based on other ethnic and religious characteristics. For example, individuals who have been subjected to ethnic slurs (such as antisemitic or anti-Muslim harassment); harassed for how they look, dress, or speak in ways related to their ethnic background (such as skin color, religious attire, or language spoken); or stereotyped based on their perceived ethnic characteristics.

disability

sex

age

retaliation because you filed a complaint or asserted your rights

Boy Scouts Equal Access Act

In the space provided below please describe each discriminatory action separately. For each action, you need to provide the following information:

• date(s) the discriminatory action occurred;
• name(s) of individual(s) who discriminated;
• what happened;
• witnesses, (if any);
• why you believe the discrimination was because of
race, sex, disability, age, or whatever basis you indicated above or
why you believe the action was retaliatory.

Do you have written information that you think will help us understand your complaint?

Yes

You will be contacted with instructions for submitting this information (please do not send original documents).

7. Your complaint must be filed within 180 days of the discriminatory action

The laws that we enforce require that complaints be filed with our office within 180 days of the alleged discriminatory event. If any of the alleged discriminatory actions took place more than 180 days before the postmark or receipt date of this complaint, you may request a waiver of the 180-day limit.

When did the last act of discrimination occur?

Enter the date:

Are you requesting a waiver of the 180-day filing time limit for discrimination that occurred more than 180 days before the filing of this complaint?

Yes

8. What would you like the institution to do as a result of your complaint?

What remedy are you seeking?

9. Option to Participate in OCR’s Early Mediation Process

OCR provides an early mediation process as an opportunity for you and the recipient institution to voluntarily resolve your complaint soon after you file it with OCR.

Mediation is a form of complaint resolution that OCR offers as an alternative to its investigative process. Mediation is an informal process in which a staff member from OCR who is trained in mediation assists the parties to reach a negotiated resolution of the complaint. The mediator does not decide who is right or wrong and does not have the authority to impose a settlement on the parties. Instead, the mediator helps the parties to find a mutually acceptable resolution to your complaint. Mediation is a strictly voluntary process. If either party does not want to participate in mediation, OCR will address the complaint through its regular processes.

If you are interested in participating in the early mediation process, you must check the box below. If you indicate your interest in early mediation by checking the box below and OCR determines that your complaint is appropriate for this process, OCR will contact you and the recipient institution and offer this resolution option. If the recipient agrees to participate in early mediation, OCR will work with you and the recipient to achieve a mutually agreeable resolution of your complaint. If the recipient does not wish to participate in early mediation, OCR will proceed with its regular processing of your complaint. If you do not indicate your interest in early mediation by checking the box below, early mediation will not be offered to you and OCR will proceed with its regular processing of your complaint.

I am interested in participating in early mediation:

10. Please read!

Please read the Information About OCR's Complaint Processing Procedures, Office for Civil Rights Notice About Investigatory Uses of Personal Information, and OCR Complaint Consent Form. All these documents are downloadable. Before we can complete initial processing of your complaint, we will need your signed consent authorizing us to proceed. Please sign and date A or B on the consent form and mail it to the OCR Enforcement Office responsible for your complaint.

Click 'submit' to send your complaint to OCR. Your complaint will be routed to the OCR office with authority to handle complaints in the state where the institution or entity you are complaining about is located. A staff person will contact you once we receive your electronic complaint form.

Please click 'Submit' only once and do not refresh the page after your submission.