Discrimination Complaint Form Page 4
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12Page 4 of 12 – U.S. Department of Education, Office for Civil Rights Discrimination
6.
What is the most recent date you were discriminated against?
Complaint Form, Consent Form, and Complaint Processing Procedures
Date:_______________________________________________________________________________
7.
If this date is more than 180 days ago, you may request a waiver of the filing
requirement.
I am requesting a waiver of the 180-day time frame for filing this complaint.
Please explain why you waited until now to file your complaint.
□
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
8.
Have you attempted to resolve these allegations with the institution through an
internal grievance procedure, appeal or due process hearing?
□ YES
□ NO
If you answered yes, please describe the allegations in your grievance or hearing,
identify the date you filed it, and tell us the status. If possible, please provide us
with a copy of your grievance or appeal or due process request and, if completed,
the decision in the matter.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
9.
If the allegations contained in this complaint have been filed with any other Federal,
state or local civil rights agency, or any Federal or state court, please give details and
dates. We will determine whether it is appropriate to investigate your complaint
based upon the specific allegations of your complaint and the actions taken by the
other agency or court.
Agency or Court:_________________________________________________________________________
Date Filed: ___________________
Case Number or Reference: __________________________________________________________
Results of Investigation/Findings by Agency or Court:
______________________________________________________________________________________________
______________________________________________________________________________________________
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