Fillable Discrimination Complaint Form (Page 6 of 12) in pdf

CONSENT FORM - FOR REVEALING NAME AND PERSONAL INFORMATION TO OTHERS

(Please print or type except for signature line)

Your Name: __________________________________________________________________________

Name of School or Other Institution That You Have Filed This Complaint Against: ______________

_____________________________________________________________________________________



This form asks whether

the Office for Civil Rights (OCR) may share your name and other personal

information when OCR decides that doing so will assist in investigating and resolving your complaint.

 For example, to decide whether a school discriminated against a person, OCR often needs to reveal that

person’s name and other personal information to employees at that school to verify facts or get additional

information. When OCR does that, OCR informs the employees that all forms of retaliation against that

person and other individuals associated with the person are prohibited. OCR may also reveal the person’s

name and personal information during interviews with witnesses and consultations with experts.

 If OCR is not allowed to reveal your name or personal information as described above, OCR may decide to

close your complaint if OCR determines it is necessary to disclose your name or personal information in

order to resolve whether the school discriminated against you.

NOTE: If you file a complaint with OCR, OCR can release certain information about your complaint to the press or

general public, including the name of the school or institution; the date your complaint was filed; the type of

discrimination included in your complaint; the date your complaint was resolved, dismissed or closed; the basic

reasons for OCR’s decision; or other related information. Any information OCR releases to the press or general

public will not include your name or the name of the person on whose behalf you filed the complaint.

NOTE: OCR requires you to respond to its requests for information. Failure to cooperate with OCR’s investigation

and resolution activities could result in the closure of your complaint.

Please sign section A or section B (but not both) and return to OCR:



If you filed the complaint on behalf of yourself, you should sign this form.



If you filed the complaint on behalf of another specific person, that other person should sign this form.

EXCEPTION:

If the complaint was filed on behalf of a specific person who is younger than 18 years old or a

legally incompetent adult, this form must be signed by the parent or legal guardian of that person.



If you filed the complaint on behalf of a class of people, rather than any specific person, you should sign the form.

A. I give OCR my consent to reveal my identity (and that of my minor child/ward on whose behalf the

complaint is filed) to others to further OCR’s investigation and enforcement activities.

_____________________________________

___________________

Signature

Date

B. I do not give OCR my consent to reveal my identity (and that of my minor child/ward on whose

behalf the complaint is filed) to others. I understand that OCR may have to close my complaint.

_____________________________________

___________________

Signature

Date

I declare under penalty of perjury that it is true and correct that I am the person named above; and, if the complaint is filed on behalf of a minor child/ward, that I am

that person’s parent or legal guardian. This declaration only applies to the identity of the persons and does not extend to any of the claims filed in the complaint.

Updated April 2014

Discrimination Complaint Form Page 6

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