Discrimination Complaint Form Page 5
Download a blank fillable Discrimination Complaint Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Discrimination Complaint Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12Page 5 of 12 – U.S. Department of Education, Office for Civil Rights Discrimination
10.
If we cannot reach you at your home or work, we would like to have the name and
Complaint Form, Consent Form, and Complaint Processing Procedures
telephone number of another person (relative or friend) who knows where and
when we can reach you. This information is not required, but it will be helpful to
us.
Last Name:____________________ First Name:____________________ Middle Name:___________________
Home Telephone______________________________ Work Telephone:______________________________
11.
What would you like the institution to do as a result of your complaint — what
remedy are you seeking?
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
12.
We cannot accept your complaint if it has not been signed. Please sign and date
your complaint below.
(Date)
(Signature)
___________
__________________________________________
(Date)
(Signature of person in Item 2)
___________
__________________________________________
Please mail the completed and signed Discrimination Complaint Form, your signed consent
form and copies of any written material or other documents you believe will help OCR
understand your complaint to the OCR Enforcement Office responsible for the state where
the institution or entity about which you are complaining is located. You can locate the
mailing information for the correct enforcement office on OCR’s website at
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal