Discrimination Complaint Form
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12United States Department of Education
Office for Civil Rights
DISCRIMINATION COMPLAINT FORM
You do not have to use this form to file a complaint with the U.S. Department of
Education’s Office for Civil Rights (OCR). You may send OCR a letter or e-mail instead
of this form, but the letter or e-mail must include the information in items one
through nine and item fourteen of this form. If you decide to use this form, please
type or print all information and use additional pages if more space is needed. An on-
line version of this form, which can be submitted electronically, can be found at:
Before completing this form please read all information contained in the enclosed packet
including: Information About OCR’s Complaint Resolution Procedures, Notice of Uses of
Personal Information and the Consent Form.
1.
Name of person filing this complaint:
Last Name:____________________ First Name:____________________ Middle Name:___________________
Address: _____________________________________________________________________________________________
City:_______________________________________________ State:_______________ Zip Code:_________________
Home Telephone:______________________________ Work Telephone:______________________________
E-mail Address: ____________________________________________________________________________________
2.
Name of person discriminated against (if other than person filing). If the person
discriminated against is age 18 or older, we will need that person’s signature on this
complaint form and the consent/release form before we can proceed with this
complaint. If the person is a minor, and you do not have the legal authority to file a
complaint on the student’s behalf, the signature of the child’s parent or legal
guardian is required.
Last Name:____________________ First Name:____________________ Middle Name:___________________
Address: _____________________________________________________________________________________________
City:_______________________________________________ State:_______________ Zip Code:_________________
Home Telephone:______________________________ Work Telephone:______________________________
E-mail Address: ____________________________________________________________________________________
Our Mission is to ensure equal access to education and to promote educational excellence throughout the Nation.
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