OFFICE FOR CIVIL RIGHTS DISCRIMINATION COMPLAINT FORM ...

Daytime Phone Number: (xxx-xxx-xxxx)Evening Phone Number:(xxx-xxx-xxxx)Relationship to You(eg. son or daughter)Injured Person's Address:City:Select State...State:Zip Code:If the person discriminated against is age 18 or older, we will need that person'ssignature before we can proceed with this complaint. If the person is a minor, and youdo not have legal authority to file a complaint on the student's behalf, the signature ofthe child's parent or legal guardian is required.4. What institution discriminated?(OCR's laws cover educational institutions such as school districts, colleges anduniversities, public libraries and state vocational rehabilitation agencies)* Institution Name:Address:City:* State:Zip Code:School or department involved:5. Have you tried to resolve the complaint through the institution's grievance process,due process hearing, or with another agency?Yes NoAgency Name:Date Filed:(mm/dd/yyyy)If yes, what is the current status of the complaint?6. Describe the discriminationOCR enforces regulations that prohibit discrimination on the basis of race, color,national origin; sex; disability; and/or age.