Discrimination Complaint Form Page 2
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12Page 2 of 12 – U.S. Department of Education, Office for Civil Rights Discrimination
Complaint Form, Consent Form, and Complaint Processing Procedures
3.
OCR investigates discrimination complaints against institutions and agencies which
receive funds from the U.S. Department of Education and against public educational
entities and libraries that are subject to the provisions of Title II of the Americans
with Disabilities Act. Please identify the institution or agency that engaged in the
alleged discrimination. If we cannot accept your complaint, we will attempt to refer
it to the appropriate agency and will notify you of that fact.
Name of Institution: _______________________________________________________________________________
Address: _____________________________________________________________________________________________
City:_______________________________________________ State:_______________ Zip Code:_________________
Department/School: ______________________________________________________________________________
4.
The regulations OCR enforces prohibit discrimination on the basis of race, color,
national origin, sex, disability, age or retaliation. Please indicate the basis of your
complaint:
Discrimination based on race (specify)
□
_____________________________________________________________________________________
______________________________________________________________________________________
Discrimination based on color (specify)
______________________________________________________________________________________
□
_____________________________________________________________________________________
______________________________________________________________________________________
Discrimination based on national origin (specify)
______________________________________________________________________________________
□
______________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________________________________________
Discrimination based on sex (specify)
□
_____________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
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