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NEW WIA EO Officer
Toolkit |
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EXAMPLE: COMPLAINT INFORMATION FORM
It is against the law for <Agency>, as a recipient of
financial assistance under Title I of the Workforce Investment Act (WIA), to
discriminate on the bases of race, color, religion, sex, national origin, age,
disability, political affiliation of belief. It is also against the law for
<Agency> to discriminate against any beneficiary of Federally
financially assisted programs on the basis of the beneficiary's citizenship/
status as a lawfully admitted immigrant authorized to work in the United
States, or his or her participation in any WIA Title I financially assisted
program or activity.
If you think that you have, or someone else has, been subjected to
discrimination by <Agency> on one of the bases listed above, you
may file a complaint within 180 days from the date of the alleged violation
with either the <Agency> or the U.S. Department of Labor's Civil
Rights Center (CRC). If you have missed this deadline and think you have good
cause for filing late, you must explain the circumstances and request an
extension from the Director of CRC at the address listed below. The Director
will determine whether you have proven good cause for an extension and notify
you of his/her determination.
To file a complaint, you may use this Complaint Information Form, or
send the information listed on this form, in writing, either to
<agency> or CRC. To file the complaint <agency> with
, send it to <provide address for complaint filing at recipient level>.
To file a complaint with CRC, send it to Director, Civil Rights Center, U.S.
Department of Labor, 200 Constitution Ave NW, Room N-4123, Washington, DC
20210. You may obtain a CRC complaint form electronically through CRC's website
at http://www.dol.gov/oasam/programs/crc/complaint.htm
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Complainant Information
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Mailing Address: |
Home Phone Number:
Work Phone Number:
Email Address:
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Please provide the name and address of the person or organization
that you believe discriminated against you or someone else. If you believe that
someone else was discriminated against, identify that person or group of people
to the best of your ability.
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Explain as briefly and clearly as possible what happened and why
you believe discrimination took place. Please give the name and contact
information for any person that witnessed the events you described above. Also
attach any written material that relates to the events you are describing.
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Please check the box or boxes that you think best represents the
reason why you believe you were, or someone else was, discriminated against. If
you are filing a complaint because you believe someone else was discriminated
against, and you do not have the exact information about that other person or
group (such as their exact date of birth, race, national origin, or type of
disability), then provide the best information that you can.
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Please explain the remedy that you are seeking.
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Signature: |
Date: |
Disclaimer: Content provided in
this toolkit does not create new legal obligations, and is not a substitute for
the U.S. Code, Code of Federal Regulations, and Federal Register, which are the
official sources for applicable statutes, regulations, notices, and other
relevant documents.
Important: In viewing the Civil Rights
Center Home Page, please take a moment to complete the Customer Survey
below.
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