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As of July 18, 2022, updates for this page are no longer available.

Please access our new form location at:
https://ocrcas.ed.gov/sites/default/files/ocr_complaint_consent_form.pdf

CONSENT FORM - FOR DISCLOSING NAME AND OTHER PERSONAL INFORMATION CONTAINED IN THE DISCRIMINATION COMPLAINT FORM 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:


  • The purpose of this consent form is for the Office for Civil Rights (OCR) to request your consent to disclose your name and other personal information contained in the Discrimination Complaint Form for OCR’s investigation of, and enforcement activities related to, the Discrimination Complaint Form.
  • For example, to decide whether a school discriminated against a person, OCR often needs to reveal that person’s name and other personal information from their complaint 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 you do not consent to OCR disclosing your name or other personal information contained in the Discrimination Complaint Form as described above, OCR may decide to close your complaint if OCR determines it is necessary to disclose such information in order to determine 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.
  1. I give OCR my consent to disclose my name (and that of my minor child/ward on whose behalf the complaint is filed) and other personal information contained in the Discrimination Complaint Form to others for OCR’s investigation of, and enforcement activities related to, the Discrimination Complaint Form.


    Signature

    Date
  2. OR
  3. I do not give OCR my consent to disclose my name (and that of my minor child/ward on whose behalf the complaint is filed) nor other personal information contained in the Discrimination Complaint Form to others for OCRs investigation of, and enforcement activities related to, the Discrimination Complaint Form. 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 by a parent or legal guardian on behalf of a minor child/individual who has been declared to be incompetent due to physical or mental incapacity or age by a court of competent jurisdiction, that I am that person’s parent or legal guardian. This declaration only provides consent for the disclosure of identity of the persons (and other individually identifiable information about them contained in the Discrimination Complaint Form) and does not extend to any of the claims filed in the complaint.

 

Updated July 18, 2022

 

 

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