SOP_NUMBER: 103.67-att-2 TITLE: Department of Justice Complaint and Consent Form DIVISION: Executive TOPIC_AREA: 103 Policy-Investigations/Compliance EFFECTIVE_DATE: 2020-12-03 WORD_COUNT: 1233 POWERDMS_URL: https://public.powerdms.com/GADOC/documents/806975 URL: https://gps.press/sop-data/103.67-att-2/ 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 ATTACHMENTS: 1. Interpreter Designation Form URL: https://gps.press/sop-data/103.67-att-1/ 2. Department of Justice Complaint and Consent Form URL: https://gps.press/sop-data/103.67-att-2/ 3. Department of Justice Complainant Consent_Release Form URL: https://gps.press/sop-data/103.67-att-3/ ======================================================================== 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**_ SOP 103.67 Attachment 2 12/3/20 Page 1 of 6 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. SOP 103.67 Attachment 2 12/3/20 Page 2 of 6 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. SOP 103.67 Attachment 2 12/3/20 Page 3 of 6 _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 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. SOP 103.67 Attachment 2 12/3/20 Page 4 of 6 _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 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. SOP 103.67 Attachment 2 12/3/20 Page 5 of 6 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. SOP 103.67 Attachment 2 12/3/20 Page 6 of 6 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.