Page 1 of 11 – U.S.

Department of Education, Office for Civil Rights Discrimination

Complaint Form, Consent Form, and Complaint Processing Procedures

United States Department of Education

Office for Civil Rights

DISCRIMINATION COMPLAINT FORM

You do not have to use this form to file a complaint with the U.S. Department of
Education’s Office for Civil Rights (OCR). You may send OCR a letter or email instead of
this form, but the letter or email must include the information in items 1-15 of this
form. If you decide to use this form, please type or print all information and use
additional pages if more space is needed. An online, fillable version of this form,
which can be submitted electronically, can be found at:
http://www.ed.gov/about/offices/list/ocr/complaintintro.html.

Before completing this form, please read all information contained in the enclosed packet
including: Information About OCR’s Complaint Resolution Procedures, Notice of Uses of Personal
Information and the Consent Form.

If you have questions about civil rights or how to file a complaint, you may contact OCR at
800-421-3481, 800-877-8339 (TTY), OCR@ed.gov, or by calling the enforcement office that serves
your state or territory. Contact information for enforcement offices can be found at:
https://ocrcas.ed.gov/contact-ocr.

If you have difficulty understanding English, you may, free of charge, request language assistance
services for this Department information by calling 1-800- USA-LEARN (1- 800-872-5327) (TTY:
1-800-877-8339), or email us at: Ed.Language.Assistance@ed.gov. If you are a person with a
disability, you may request disability-related assistance by contacting OCR at 800-421-3481, 800-
877-8339 (TTY), OCR@ed.gov, or by calling the enforcement office that serves your state or
territory. Contact information for enforcement offices can be found at:
https://ocrcas.ed.gov/contact-ocr. To request this document in an alternate format such as Braille
or large print please contact the Department at 202-260-0852 or om_eeos@ed.gov.

Our mission is to ensure equal access to education and to promote educational excellence nationwide through the
enforcement of civil rights.
Page 2 of 11 – U.S. Department of Education, Office for Civil Rights Discrimination
Complaint Form, Consent Form, and Complaint Processing Procedures

1. Name of person filing this complaint:

Last Name: ____________________ First Name: _____________________ Pronoun: ____________________

Address: ______________________________________________________________________________________________

City:_______________________________________________ State:_______________ Zip Code:________________

Primary number:______________________________ Alternate number:___________________________

Email Address: ____________________________________________________________

2. Name of person discriminated against (if other than person filing). If the person discriminated
against is age 18 or older, we will need that person’s signature on this complaint form and the
consent/release form before we can proceed with this complaint. If the person is a minor, and
you do not have the legal authority to file a complaint on the student’s behalf, the signature of
the child’s parent, guardian, or other authorized legal representative is required.

Last Name:____________________ First Name: _____________________ Pronoun: ____________________

Address: _____________________________________________________________________________________________

City:_______________________________________________ State:_______________ Zip Code:_________________

Primary Phone:______________________________ Alternative Phone:______________________________

Email Address:

3. OCR investigates discrimination complaints against schools, colleges and universities,

institutions, and agencies which receive funds or other forms of financial assistance
from the U.S. Department of Education and against public educational entities and
libraries that are subject to the provisions of Title II of the Americans with Disabilities
Act. Please identify the institution or agency that engaged in the alleged
discrimination. If we cannot accept your complaint, we will attempt to refer it to the
appropriate agency and will notify you of that fact.

Name of Institution: _______________________________________________________________________________

Address: _____________________________________________________________________________________________

City:_______________________________________________ State:_______________ Zip Code:_________________

Department/School: ______________________________________________________________________________

4. The regulations OCR enforces prohibit discrimination on the basis of race, color,
national origin, sex, disability, or age. The regulations also ban retaliation against
persons who assert the right to be free from discrimination. Please note the following:

• Discrimination based on race, color, and national origin includes failure to

provide meaningful access to English learners and limited English proficient
parents and guardians, as well as discrimination based on shared ancestry or
ethnic characteristics or based on citizenship in a country with a dominant
religion.
Our mission is to ensure equal access to education and to promote educational excellence nationwide through the
enforcement of civil rights.
Page 3 of 11 – U.S. Department of Education, Office for Civil Rights Discrimination
Complaint Form, Consent Form, and Complaint Processing Procedures
Discrimination based on race, color, and national origin also includes discrimination, including
harassment, because you and/or another individual are, for example, Jewish, Muslim, Arab,
Hindu, or Sikh; or based on other ethnic and religious characteristics. For example, individuals
who have been subjected to ethnic slurs (such as antisemitic or anti-Muslim harassment);
harassed for how they look, dress, or speak in ways related to their ethnic background (such as
skin color, religious attire, or language spoken); or stereotyped based on their perceived ethnic
characteristics.

• Discrimination based on sex includes discrimination based on sex stereotypes,

pregnancy or related conditions, sexual orientation, and gender identity, as well
as rules about parental, family, or marital status that treat people differently
based on sex.

• Discrimination based on disability includes discrimination against individuals

who have a physical or mental impairment that substantially limits a major life
activity, as well as individuals who have a record of or are regarded as having a
disability.

• Discrimination based on age does not limit protection against discrimination to

a certain age group (e.g., people over 40); however, there are a variety of
exceptions to the relevant Federal law that may permit age to be taken into
account.

• Retaliation refers to actions taken for the purpose of interfering with any rights
under the laws enforced by OCR, or because you made a complaint, testified, or
participated in any manner in an OCR proceeding.

Please indicate the basis of your complaint:

Discrimination based on race (specify)

Discrimination based on color (specify)

Discrimination based on national origin (specify)

Our mission is to ensure equal access to education and to promote educational excellence nationwide through the
enforcement of civil rights.
Page 4 of 11 – U.S. Department of Education, Office for Civil Rights Discrimination
Complaint Form, Consent Form, and Complaint Processing Procedures

Discrimination based on sex (specify)

Discrimination based on disability (specify)

Discrimination based on age (specify)

Retaliation because you filed a complaint or otherwise asserted rights

under laws enforced by OCR (specify)

Violation of the Boy Scouts of America Equal Access Act (specify)

Our mission is to ensure equal access to education and to promote educational excellence nationwide through the
enforcement of civil rights.
Page 5 of 11 – U.S. Department of Education, Office for Civil Rights Discrimination
Complaint Form, Consent Form, and Complaint Processing Procedures

5. Please describe each alleged discriminatory act. For each action, please include the
date(s) the discriminatory act occurred, the name(s) of each person(s) involved and,
why you believe the discrimination was because of race, disability, age, sex, etc. Also
please provide the names of any person(s) who was present and witnessed the act(s)
of discrimination.

6. Do you have documents or written information that you think will help us to understand your
complaint?
□ No
□ Yes

If yes, please describe the documents or written information you have.

If OCR investigates your complaint, we may ask you to provide us the items you
describe above.

7. What is the most recent date you were discriminated against?

Date:_______________________________________________________________________________

8. If this date is more than 180 days ago, you may request a waiver of the filing
requirement.

I am requesting a waiver of the 180-day time frame for filing this complaint.

Please explain why did not file your complaint within 180 days.

Our mission is to ensure equal access to education and to promote educational excellence nationwide through the
enforcement of civil rights.
Page 6 of 11 – U.S. Department of Education, Office for Civil Rights Discrimination
Complaint Form, Consent Form, and Complaint Processing Procedures

9. Have you complained about the allegations that you raise in this complaint to your
school, institution, or another organization or agency?

YES NO

If yes, have you complained about the allegations that you raise in this complaint
by:

filing an internal complaint or appeal with your school or institution?

participating in your school or institution’s grievance procedures?

participating in a due process hearing either at your school or institution, or

through another organization or government agency?

If you answered yes to any of the above questions, please describe the
allegations that you raised in an internal complaint or appeal, through your school or
institution’s grievance procedures, or in a due process hearing, identify the date you
complained about the allegations and where you made the complaint, and tell us
the status of the complaint, appeal, grievance procedures, or due process hearing.
If possible, please provide us with a copy of your complaint or grievance or appeal
or due process request and, if completed, the decision in the matter.

10. If the allegations contained in this complaint have been filed with any other Federal,
state or local civil rights agency, or any Federal or state court, please give details and
dates. We will determine whether it is appropriate to investigate your complaint
based upon the specific allegations of your complaint and the actions taken by the
other agency or court.

Agency or Court:_________________________________________________________________________

Date Filed: ___________________

Case Number or Reference: __________________________________________________________

Results of Investigation/Findings by Agency or Court:

Our mission is to ensure equal access to education and to promote educational excellence nationwide through the
enforcement of civil rights.
Page 7 of 11 – U.S. Department of Education, Office for Civil Rights Discrimination
Complaint Form, Consent Form, and Complaint Processing Procedures

11. You do not need to have a lawyer to file a complaint with OCR; however, if you do have a lawyer,
OCR staff are required to communicate directly with your lawyer. If you have a lawyer
representing you in this matter, please provide the lawyer’s contact information.

Last Name:_____________________________________ First Name:_________________________________

Telephone: ______________________________ Email:_____________________________________________

12. If we cannot reach you at your home or work, we would like to have the name and
telephone number of another person (relative or friend) who knows where and when
we can reach you. This information is not required, but it will be helpful to us.

Last Name:_____________________________________ First Name:_________________________________

Telephone: ______________________________ Email:_____________________________________________

13. Option to Participate in OCR’s Early Mediation Process

OCR provides an early mediation process as an opportunity for you and the recipient institution
to voluntarily resolve your complaint soon after you file it with OCR.

Mediation is a form of complaint resolution that OCR offers as an alternative to its investigative
process. Mediation is an informal process in which a staff member from OCR who is trained in
mediation assists the parties to reach a negotiated resolution of the complaint. The mediator
does not decide who is right or wrong and does not have the authority to impose a settlement on
the parties. Instead, the mediator helps the parties to find a mutually acceptable resolution to
your complaint. Mediation is a strictly voluntary process. If either party does not want to
participate in mediation, OCR will address the complaint through its regular processes.

If you are interested in participating in the early mediation process, you must check the box
below. If you indicate your interest in early mediation by checking the box below and OCR
determines that your complaint is appropriate for this process, OCR will contact you and the
recipient institution and offer this resolution option. If the recipient agrees to participate in
early mediation, OCR will work with you and the recipient to achieve a mutually agreeable
resolution of your complaint. If the recipient does not wish to participate in early mediation,
OCR will proceed with its regular processing of your complaint. If you do not indicate your
interest in early mediation by checking the box below, early mediation will not be offered to
you and OCR will proceed with its regular processing of your complaint.

I am interested in participating in early mediation (Please check box): [ ]

NOTE: You MUST submit a signed Consent Form to OCR if you want to participate in early
mediation.

Our mission is to ensure equal access to education and to promote educational excellence nationwide through the
enforcement of civil rights.
Page 8 of 11 – U.S. Department of Education, Office for Civil Rights Discrimination
Complaint Form, Consent Form, and Complaint Processing Procedures

14. What would you like the institution to do as a result of your complaint
— what remedy are you seeking?

15. We cannot accept your complaint if it has not been signed. Please
sign and date your complaint below.

___________ __________________________________________
(Date) (Signature)

___________ __________________________________________
(Date) (Signature of person in Item 2)

Please mail or email the completed and signed Discrimination Complaint Form, your signed
consent form and copies of any written material or other documents you believe will help
OCR understand your complaint to the OCR Enforcement Office responsible for the state
where the institution or entity about which you are complaining is located. You can locate
the mailing information for the correct enforcement office on OCR’s website at
https://ocrcas.ed.gov/contact-ocr.

Our mission is to ensure equal access to education and to promote educational excellence nationwide through the
enforcement of civil rights.
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 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 you do not consent to OCR disclosing your name or other personal information, 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.

A. 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

OR
B. 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 OCR’s 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 October 30, 2023

 Updated July 2022

Excerpt from the Online Interactive Complaint Form

Race / Color / National Origin / Ethnicity / Shared Ancestry

Discrimination based on national origin includes discrimination based on the country, world region, or place
where a person or their ancestors come from; a person's limited English proficiency or English learner status; and
a person's actual or perceived shared ancestry or ethnic characteristics, including membership in a religion that
may be perceived to exhibit such characteristics (e.g., Hindu, Jewish, Muslim, and Sikh students). For more
information about race, color, and national origin discrimination, please visit www.ed.gov/ocr/frontpage/pro-
students/race-origin-pr.html.

Sex

Discrimination based on sex includes discrimination based on sex stereotypes, pregnancy or related conditions,
sexual orientation, and gender identity. Discrimination based on sex also encompasses rules about parental,
family, or marital status that treat people differently based on sex. For more information about sex
discrimination, please visit https://www2.ed.gov/policy/rights/guid/ocr/sexoverview.html.

Disability

A person with a disability is defined as any person who (i) has a physical or mental impairment, which
substantially limits one or more major life activities, or (ii) has a record of such impairment, or (iii) is regarded
as having such an impairment. Whether a person has a disability is determined without considering mitigating
measures. For more information about disability discrimination, please
visit www.ed.gov/policy/rights/guid/ocr/disability.html.

Our mission is to ensure equal access to education and to promote educational excellence nationwide through the
enforcement of civil rights.