U.S. Department of Education: Promoting Educational Excellence for all Americans

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United States Department of Education

Office for Civil Rights

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: ________________ _____________________________________________________________________________________

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

 

 

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

OR

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

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