Filing a complaint with OCR is voluntary. However, without the information requested, OCR may be unable to proceed with your complaint. OCR collects this information under authority of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of1973 and other civil rights statutes. They will use the information you provide to determine if they have jurisdiction and, if so, how they will process your complaint. Information submitted on this form is treated confidentially and is protected under the provisions of the Privacy Act of 1974. Names or other identifying information about individuals are disclosed when it is necessary for investigation of possible discrimination, for internal systems operations, or for routine uses, which include disclosure of information outside the Department of Health and Human Services (HHS) for purposes associated with civil rights compliance and as permitted by law. It is illegal for a recipient of Federal financial assistance from HHS to intimidate, threaten, coerce, or discriminate or retaliate against you for filing this complaint or for taking any other action to enforce your rights under Federal civil rights laws. You are not required to use this form. You also may write a letter or submit a complaint electronically with the same information.
To submit an electronic complaint, go to OCR’s web site at: http://www2.ed.gov/about/offices/list/ocr/complaintintro.html
Printable form at http://www.hhs.gov/ocr/civilrights/complaints/discrimhowtofile.pdf