To print: Click here or Select File and then Print from your browser's menu
Complainant's Name (print or type): _______________________________________
Institution Against Which Complaint Filed: ___________________________________
Please sign and date section A or section B and return to the above address:
I have read the Notice about Investigatory Uses of Personal Information. I understand that the Privacy Act of 1974, 5 U.S.C. § 552a, and the Freedom of Information Act (FOIA), 5 U.S.C. § 552, govern the use of personal information submitted to all Federal agencies and their individual components, including OCR. I will cooperate with OCR's investigation and complaint resolution activities undertaken on my behalf. I understand that my failure to cooperate with OCR’s investigation may result in the closure of my complaint.A. I give OCR my consent to reveal my identity (and/or that of my minor child/ward on whose behalf the complaint is filed) to the institution alleged to have discriminated, as well as other persons and entities outside if OCR, in the course of its investigation or for enforcement activities, finds it necessary to do so.
ORB. I do not give OCR my consent to reveal my identity (and/or that of my minor child/ward on whose behalf the complaint is filed). I understand that OCR may have to close this complaint if OCR is unable to proceed with an investigation without releasing my identity (and/or that of my minor child/ward on whose behalf the complaint is filed).
Alternatively, if you are not filing this complaint on your own behalf or on behalf of your own minor child/ ward, you are responsible for obtaining written consent from the person on whose behalf the complaint is filed or, if he or she is a minor, that person’s parent/ guardian.
I have read this document, and I agree with the person who filed this complaint. I wish you to proceed with OCR's investigation and resolution process. I give my consent for OCR to reveal my identity to other persons to the extent necessary for the purpose of resolution or investigation of this complaint.
Name (print or type): __________________________________________________
Eff. date: January 2010