SOP 103.67-att-2: Department of Justice Complaint and Consent Form

Division:: Executive
Effective Date:: December 3, 2020
Topic Area:: 103 Policy-Investigations/Compliance
PowerDMS:: View on PowerDMS
Length:: 1,233 words

Summary

This form is used to file discrimination complaints with the Federal Coordination and Compliance Section (FCS) of the Georgia Department of Corrections. It collects information about alleged discrimination based on protected characteristics such as race, national origin, sex, religion, age, or disability in either employment or service delivery. The form is optional but must contain certain required information fields to be valid.

Key Topics

discrimination complaint
federal compliance
DOJ complaint
equal opportunity
employment discrimination
service delivery discrimination
protected class
civil rights
Title VI
Omnibus Crime Control and Safe Streets Act
FCS
filing deadline
180 days

Full Text

# GEORGIA DEPARTMENT OF CORRECTIONS

_Office of Professional Standards_

_State Offices South at Tift College_

_P. O. Box 1529_
_Forsyth, Georgia 31029_

_Phone: (478) 992-5374_

_Fax: (478) 994-7752_

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Timothy C. Ward

_Commissioner_

Brian P. Kemp
_Governor_

Department of Justice Complaint Form

The purpose of this form is to assist you in filing a complaint with the Federal Coordination and Compliance
Section (FCS). You are not required to use this form; a letter with the same information is sufficient.
However, the information requested in the items marked with a star (*) must be provided if you submit
something other than this form.

1.* Your name and address:

Name: _______________________________________________________________________________________

Address: _____________________________________________________________________________________

______________________________________________________________________ Zip ___________________

Telephone: Home: ( ) Work or Cell: ( )_______________________________

2.* Person(s) discriminated against, if different from above:

Name: _______________________________________________________________________________________

Address: _____________________________________________________________________________________

______________________________________________________________________ Zip ___________________

Telephone: Home: ( ) Work or Cell: ( )____________________________

Please explain your relationship to this person(s).

_____________________________________________________________________________________________

3.* Agency and department or program that discriminated:

Name: _______________________________________________________________________________________

Address: _____________________________________________________________________________________

______________________________________________________________________ Zip ___________________

Telephone: Home: ( ) Work or Cell: ( ) _______________________________

4A.* Non-employment: Does your complaint concern discrimination in the delivery of services or in other
discriminatory actions of the department or agency in its treatment of you or others? If so, please indicate below the
base(s) on which you believe these discriminatory actions were taken:

____ Race/Ethnicity: ________________________________

____ National origin: ________________________________

____ Sex: _________________________________________

____ Religion: _____________________________________

____ Age: _________________________________________

____ Disability: ____________________________________

_Equal Opportunity Employer_

Record Retention: Upon completion, this form will be retained permanently in the employee’s official and local personnel files.

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4B.* Employment: Does your complaint concern discrimination in employment by the department or agency? If so,
please indicate below the base(s) on which you believe these discriminatory actions were taken:

____ Race/Ethnicity: ________________________________
____ National origin: ________________________________
____ Sex: _________________________________________
____ Religion: _____________________________________
____ Age: _________________________________________
____ Disability: ____________________________________

5. What is the most convenient time and place for us to contact you about this complaint?
_____________________________________________________________________________________________

6. If we will not be able to reach you directly, you may wish to give us the name and phone number of a person who
can tell us how to reach you and/or provide information about your complaint:

Name:________________________________________________________________________________________

Telephone: Home: ( ) Work or Cell: ( )________________________________

7. If you have an attorney representing you concerning the matters raised in this complaint,
please provide the following:

Name: _______________________________________________________________________________________
Address: ______________________________________________________________________________________
______________________________________________________________________ Zip ___________________
Telephone: Home: ( ) Work or Cell: ( )________________________________

8.* To your best recollection, on what date(s) did the alleged discrimination take place?

Earliest date of discrimination: _________________________________

Most recent date of discrimination: ______________________________

9. Complaints of discrimination generally must be filed within 180 days of the alleged discrimination. If the most
recent date of discrimination, listed above, is more than 180 days ago, you may request a waiver of the filing
requirement. If you wish to request a waiver, please explain why you waited until now to file your complaint and FCS
will evaluate the explanation and decide if a waiver is appropriate:

10.* Please explain, as clearly and neatly as possible, what happened, why you believe it happened, and how you were
discriminated against. Indicate who was involved. Be sure to include how other persons were treated differently from
you. (Please use additional sheets if necessary and attach a copy of written materials pertaining to your case.)

_Equal Opportunity Employer_

Record Retention: Upon completion, this form will be retained permanently in the employee’s official and local personnel files.

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_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

11. Title VI of the Civil Rights Acts of 1964, 42 U.S.C. §§ 2000d – 2000d7 and the nondiscrimination
section of the Omnibus Crime Control and Safe Streets Act of 1968, 28 U.S.C.§ 3789d(c), prohibit
recipients of Department of Justice funds from intimidating or retaliating against anyone because he or she
has either taken action or participated in an action to secure rights protected by these laws. If you believe
that you have been retaliated against (separate from the discrimination alleged in #10), please explain, as
clearly and neatly as possible, the circumstances below. Be sure to explain what actions you took which
you believe were the basis for the alleged retaliation:

12. Please list below any persons (witnesses, fellow employees, supervisors, or others), if known, whom
we may contact for additional information to support or clarify your complaint:

Name Address Area Code/Telephone

13. Do you have any other information that you think is relevant to our investigation of your
allegations?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

_Equal Opportunity Employer_

Record Retention: Upon completion, this form will be retained permanently in the employee’s official and local personnel files.

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14. What remedy are you seeking for the alleged discrimination?

15. Have you (or the person discriminated against) filed the same or any other complaints with other offices
of the Department of Justice (including the Office of Justice Programs, Federal Bureau of Investigation,
etc.) or other Federal agencies?

Yes _____ No ______

If so, do you remember the Complaint Number? ______________________________________________

What agency and department or program was it filed with?

_____________________________________________________________________________________

Name: _______________________________________________________________________________
Address: ____________________________________________________________________________
_____________________________________________________________ Zip ___________________
Telephone No: ( ) _____________________________________

Date of Filing: ____________________________ Filed Against: _______________________________

Briefly, what was the complaint about?

What was the result?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

16. Have you filed a charge or complaint concerning the matters raised in this complaint with any of the
following?

____ U.S. Equal Employment Opportunity Commission

____ Federal or State Court

____ Your State or local Human Relations/Rights Commission

____Grievance or complaint office

____ Other

_Equal Opportunity Employer_

Record Retention: Upon completion, this form will be retained permanently in the employee’s official and local personnel files.

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17. If you have already filed a charge or complaint with an agency indicated in #16, above, please provide
the following information (attach additional pages if necessary):

Agency: _____________________________________________________________________________

Date filed: ____________________________________________________________________________

Case or Docket Number: ________________________________________________________________

Date of Trial/Hearing: __________________________________________________________________

Location of Agency/Court: ______________________________________________________________

Name of Investigator: __________________________________________________________________

Status of Case: ________________________________________________________________________

Comments: __________________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________

18. While it is not necessary for you to know about aid that the agency or institution you are filing against
receives from the Federal government, if you know of any Department of Justice funds or assistance
received by the program or department in which the alleged discrimination occurred, please provide that
information below.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

19.* We cannot accept a complaint if it has not been signed. Please sign and date this Complaint Form
below.

_____________________________________________________________________________________
(Signature) (Date)

Please feel free to add additional sheets to explain the present situation to us.

We will need your consent to disclose your name, if necessary, in the course of any investigation. Therefore,
we will need a signed Consent Form from you. (If you are filing this complaint for a person whom you
allege has been discriminated against, we will in most instances need a signed Consent Form from that
person.) See the "Notice about Investigatory Uses of Personal Information" for information about the
Consent Form. Please mail the completed, signed Discrimination Complaint Form and the signed Consent
Form (please make one copy of each for your records) to:

United States Department of Justice

Civil Rights Division
Federal Coordination and Compliance Section - NWB

950 Pennsylvania Avenue, NW

Washington, D.C. 20530

Toll-free Voice and TDD: (888) 848-5306

Voice: (202) 307-2222

TDD: (202) 307-2678

_Equal Opportunity Employer_

Record Retention: Upon completion, this form will be retained permanently in the employee’s official and local personnel files.

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20. How did you learn that you could file this complaint?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

21. If your complaint has already been assigned a DOJ complaint number, please list it here:

______________________________________________

Note: If a currently valid OMB control number is not displayed on the first page, you are not required to
fill out this complaint form unless the Department of Justice has begun an administrative investigation into
this complaint.

_Equal Opportunity Employer_

Record Retention: Upon completion, this form will be retained permanently in the employee’s official and local personnel files.

Attachments (3)

Interpreter Designation Form (207 words)
Department of Justice Complaint and Consent Form (1,233 words)
Department of Justice Complainant Consent_Release Form (382 words)

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