Va Form 10-0381 - Civil Rights Discrimination Complaint

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OMB Number 2900-0662

Estimated burden: 15 minutes

CIVIL RIGHTS DISCRIMINATION COMPLAINT

USE AN ADDITIONAL SHEET OF PAPER TO ANSWER ANY QUESTION IF NECESSARY.

PRIVACY ACT INFORMATION: The information requested on this form is solicited under authority of Title 38, Code of Federal Regulations, Chapter 1, Parts 15 and 18, and is used by

patients and other VHA customers to file a formal complaint for alleged violations of their civil rights pertaining to race, color, sex, national origin, age, disability, or reprisal. The information

you supply may also be disclosed outside the VA as permitted by law or as stated in the "Notices of Systems of VA Records" 16VA026 Litigant, Tort Claimant, EEO Complainant, and Third

Party Recovery Files-VA and 63VA05 Grievance Records-VA published in the Federal Register. Disclosure is voluntary, however; failure to furnish the information will result in our inability to

process your request promptly and adjudicate your grievance needs. Failure to furnish the information will have no adverse effect on any other benefits to which you may be entitled.

The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of this Act. The public

reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and

maintaining the data needed, and completing and reviewing the collection of information. Respondents should be aware that notwithstanding any other provision of law, no person shall be

subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. Completion of this form is entirely voluntary. Failure to

complete the form will have no adverse impact on any benefits to which you may have been entitled. The purpose of this information collection is to help you explain an event you consider

discriminatory.

(Last, First, Middle Initial)

2. MAILING ADDRESS

1. NAME

(Include area code)

3A. WORK TELEPHONE NO.

(Include area code)

4. NAME AND ADDRESS OF VA FACILITY OR OTHER AGENCY WHERE DISCRIMINATION OCCURRED.

3B. HOME TELEPHONE NO.

5. NAME OF SERVICE/PRODUCT LINE WHERE DISCRIMINATION OCCURRED.

If known)

(Include