SOP 103.67-att-3: Department of Justice Complainant Consent_Release Form

# 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 3

12/3/20

Timothy C. Ward

_Commissioner_

Brian P. Kemp
_Governor_

Department of Justice Complainant Consent/Release Form

Your Name: __________________________________________________________________________

Address: ____________________________________________________________________________

_____________________________________________________________________________________

Complaint number(s): (if known) _________________________________________________________

_Please read the information below, check the appropriate box, and sign this form._

I have read the Notice of Investigatory Uses of Personal Information by the Department of Justice (DOJ).
As a complainant, I understand that in the course of an investigation it may become necessary for DOJ to
reveal my identity to persons at the organization or institution under investigation. I am also aware of the
obligations of DOJ to honor requests under the Freedom of Information Act. I understand that it may be
necessary for DOJ to disclose information, including personally identifying details, that it has gathered as
a part of its investigation of my complaint. In addition, I understand that as a complainant I am protected
by DOJ’s regulations from intimidation or retaliation for having taken action or participated in action to
secure rights protected by nondiscrimination statutes enforced by DOJ.

CONSENT/RELEASE

CONSENT - I have read and understand the above information and authorize DOJ to reveal my
identity to persons at the organization or institution under investigation. I hereby authorize the
Department of Justice (DOJ) to receive material and information about me pertinent to the
investigation of my complaint. This release includes, but is not limited to, personal records and
medical records. I understand that the material and information will be used for authorized civil
rights compliance and enforcement activities. I further understand that I am not required to
authorize this release and do so voluntarily.

CONSENT DENIED - I have read and understand the above information and do not want DOJ to
reveal my identity to the organization or institution under investigation, or to review, receive
copies of, or discuss material and information about me, pertinent to the investigation of my
complaint. I understand this is likely to impede the investigation of my complaint and may result
in the closure of the investigation.

_____________________________________________________________________________________
SIGNATURE DATE

_Equal Opportunity Employer_

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