# ![](media/image1.wmf){width="0.6381944444444444in" height="0.5125in"}Complaint Information Form U.S. Department of Labor 

**Civil Rights Center**

1\. Complainant Information:

State your name and address:

Your telephone number(s):

Home Number: **( ) -**

Work Number: **( ) -**

2\. Respondent Information:

Provide name and address of agency involved:

Telephone Number: **( ) -**

3\. What is the most convenient time and place for us to contact you
about this complaint?

4\. To your best recollection on what date(s) did the discrimination
take place?

Date of first occurrence:

Date of most recent occurrence:

5\. Have you ever attempted to resolve this complaint at the local
Level?  No or  Yes

a\. Have you been provided with a final decision at the local level
regarding your complaint?

>  No  Yes
>
> Date of final decision (if any)

b\. Have 90 days elapsed since you filed or attempted to file this
complaint at the local level?

>  No  Yes
>
> Date you filed or attempted to file your complaint at the local level.

6 .Explain as briefly and clearly as possible what happened and how you
were discriminated against. Indicate who was involved. Be sure to
include how other persons were treated differently from you. Also attach
any written material pertaining to your case.

**For DOL use only**

**CIF Received by CRC: \_\_\_\_\_Accepted \_\_\_\_\_ Not Accepted Case
Number \_\_\_\_\_**

**By: Date:**

**OMB Control Number 1225-0077 Exp. Date 5/31/2011 DL 1-2014a
(Rev'6/87)**

7\. To the best of your knowledge, which of the following Department of
Labor programs were involved? (Check one)

 Workforce Investment Act (WIA)

 Job Training (JTPA)

 MSHA

 Welfare to Work

 OSHA

 Job Service

 WIN

 Youth

 Unemployment Insurance

 Job Corps

 Apprenticeship

 Older Americans

 New Directions

 Displaced Worker

 Other: Specify

8\. Basis of Complaint: Which of the follow­ing best describes why you
believe you were discriminated against: (Check)

 Race: Specify

 Color: Specify

 Religion: Specify

 National Origin: Specify

 Sex: Specify \[ \] Male \[ \] Female

 Age: Specify Date of Birth:

 Disability: Specify

 Political Affiliation: Specify

 Citizenship: Specify

 Reprisal/Retaliation: Specify

 Other: Specify

9\. Do you think the discrimination against you involved: (Check one)

 Your job or seeking employment?

or

 Your using facilities or someone providing/not providing you with
services or benefits?

If so, which of the following are involved?

 Hiring  Harassment

 Transition  Access/Accommodation

 Wages  Union Representation

 Job Classification  Union Activity

 Discharge/Termination  Application

 Promotion  Enrollment

 Training  Referral

 Transfer  Exclusion

 Qualification/Testing  Placement

 Grievance Procedure  Benefits

 Layoff/Furlough  Performance Appraisal

 Recall (From Layoff-Furlough)  Discipline/Reprimand

 Seniority  Intimidation/Reprisal

 Other: Specify

10\. Why do you believe these events occurred?

11\. What other Information do you think is relevant to our
investigation?

12\. If this complaint is resolved to your satisfaction, what remedies
do you seek?

13\. Please list below any persons (witnesses, fellow employees,
supervisors, or others) that we may contact for additional information
to support or clarify your complaint:

[Name]{.underline} [Address]{.underline} [Telephone Number]{.underline}

14\. Do you have an attorney?

 Yes  No

If yes, please provide name, address and phone:

[Attorney Name]{.underline} [Address]{.underline} [Telephone
Number]{.underline}

15\. Have you filed a case or complaint with any of the following?

 Civil Rights Division, U S Dept of Justice

 U S Equal Employment Opportunity Commission

 Federal or State court

 Your State or local Human Relations/Rights Commission

16\. For each item checked in #15 above, please provide the following
Information:

Agency:

Data Filed:

Case or Docket Number

Date of Trial or Hearing:

Location of agency or court

Name of Investigator:

Status of Case:

Comments:

17\. Sign (Complaint NOT VALID unless signed)

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Name: Date:

**U.S. Department of Labor, Civil Rights Center**

**NOTICE ABOUT INVESTIGATORY USES OF PERSONAL INFORMATION**

Two Federal laws govern personal information to Federal agencies,
including the Civil Rights Center (CRC), the Privacy Act of 1974, (5
U.S.C. 552) and the Freedom of Information Act (5 U.S.C. 552) or "FOIA".
Please read the description of how these laws apply to information
connected with your complaint. After reading this notice, please sign
and return the consent agreement printed on the back of this notice,
along with your complaint form.

The PRIVACY ACT protects individuals from misuse of personal information
held by the Federal Government. The law applies to records that are kept
and can be located by the individual's name, social security number, or
other personal identification system. Anyone who submits information to
CRC in connection with a discrimination complaint should know the
following:

-   CRC has been authorized to investigate complaints of discrimination
    on the basis of race, color, national origin, age, and handicap and
    in some programs on the basis of sex, religion, citizenship, and
    political affiliation or belief, in programs that receive Federal
    funds through the Department of Labor, CRC is also authorized to
    conduct reviews of federal funded program to assess their compliance
    with civil rights laws.

-   Information that CRC collects is analyzed by authorized personnel
    with CRC. This information may include personnel or program
    participant records, and other personal information. CRC staff may
    want to reveal some of the personal information to individuals
    outside the office in order to verify facts related to the
    complaint, or to discover new facts which will help CRC determine
    whether the law has been violated. Such information could include,
    for example, the physical condition or age of a complainant. CRC may
    also have to reveal personal information to a person who submits a
    request for disclosure authorized by the Freedom of Information Act.

-   Information submitted to CRC may also be revealed to persons outside
    of CRC because it is necessary in order to complete enforcement
    proceedings against a program that CRC finds to have violated the
    law or regulations. Such information could include, for example, the
    name, income, age, marital status or physical condition of the
    complainant.

-   Any personal information you provide may be used only for the
    specific purpose for which it was requested. CRC requests personal
    information only for the purpose of carrying out authorized
    activities to enforce, and determine compliance with, civil rights
    laws and regulations. CRC will not release personal information to
    any person or organization unless the person who submitted the
    information gives written consent, or unless release is required by
    the Freedom of Information Act.

-   No law requires that a complainant reveal personal information CRC,
    and no action will be taken against a person who denies CRC's
    request for personal information. However, if CRC cannot obtain the
    information needed to fully investigate the allegations in the
    complaint, CRC may close the case.

-   Any person may ask for, and receive, copies of all personal
    materials CRC keeps in his or her file for investigatory use.

AS A POLICY, CRC DOES NOT REVEAL NAMES AND OTHER IDENTIFYING INFORMATION
ABOUT INDIVIDUALS UNLESS IT IS NECESSARY TO COMPLETE INVESTIGATION OR
ENFORCEMENT ACTIVITIES AGAINST A PROGRAM WHICH HAS VIOLATED THE LAW. CRC
never reveals to the program under investigation the identity of the
person who filed the complaint, unless the complainant first gave CRC
written permission to do so.

The FREEDOM OF INFORMATION ACT (FOIA) gives the public maximum access to
Federal government files and records. Persons can request and receive
information from many types of records kept by the Federal
government-not just materials that apply to them personally. The Civil
Rights Center must honor most requests for information submitted under
FOIA, but there are exceptions.

-   CRC is usually not required to release information during an
    investigation or an enforcement proceeding if that release would
    limit CRC's ability to do its job effectively; and

-   CRC can refuse to disclose information if release would result in a
    "clearly unwarranted invasion" of a person's privacy.

PLEASE READ AND SIGN SECTION A OR SECTION B OF THE CONSENT FORM PRINTED
ON THE BACK OF THIS NOTICE, AND RETURN IT TO THE CIVIL RIGHTS CENTER
WITH YOUR SIGNED COMPLETED COMPLAINT INFORMATION FORM.

> **CONSENT FORM**

I have read the Notice about Investigatory Uses of Personal Information,
printed on the front of this form. I understand the following provisions
of the Privacy Act and Freedom of Information Act, which apply to
personal information I reveal to the Civil Rights Center in connection
with my complaint:

In the course of investigating my complaint, CRC may have to reveal my
identity to staff of the program named in my complaint in order to
obtain facts and evidence regarding my complaint;

I do not have to reveal any personal information to CRC, but CRC may
close my complaint if I refuse to reveal information needed to fully
investigate my complaint;

I may request and receive a copy of any personal information CRC keeps
in my complaint file for investigatory uses; and

Under certain conditions, CRC may be required by the Freedom of
Information Act to reveal to others personal information I have provided
in connection with my complaint.

**SECTION A**

\[ \] YES, CRC MAY DISCLOSE MY IDENTITY IF NECESSARY TO INVESTIGATE MY
COMPLAINT. I have read and understand the notice, and I consent for CRC
to disclose my identity during investigation of my complaint.

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\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Signature) (Date)

**SECTION B**

\[ \] NO, CRC MAY NOT DISCLOSE MY IDENTITY, EVEN IF NECESSARY TO PROCESS
MY COMPLAINT. I have read and understand the notice, and I do not
consent for CRC to disclose my identity during investigation on of my
complaint. I request that CRC process my complaint, however, I
understand that CRC may cancel my complaint if it cannot fully
investigate without disclosing my identity. I also understand CRC may
close my complaint if it cannot begin an investigation because I have
not consented for CRC to reveal my identity.

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

(Signature) (Date)

Persons are not required to respond to a collection of information
unless it displays a currently valid OMB control number. Completing this
form is voluntary; however, the requested information must be provided
in order to file a complaint of discrimination. The Department of
Labor\'s Civil Rights Center will use the information to investigate
your complaint of discrimination. The estimated average response time to
complete this form is 15 minutes per response. Send comments regarding
this estimate or any other aspects of this collection of information to
the U.S. Department of Labor, Office of the Assistant Secretary for
Administration and Management, Civil Rights Center, Room N-4123,
Washington, D.C. 20210. Please reference OMB control number 1225-0077.