19. Please explain what happened to you (you may use additional pages if necessary). Attach any supporting documents to your complaint.
20. Please explain how you would like to see this complaint resolved? (you may use additional pages if necessary).
16. Agency/Bureau/Office/Post where the alleged act/event occurred.
6. Best Time to Reach You
2. Home Phone Number1. Name (last, first, m)
U.S. Department of State
DISCRIMINATION COMPLAINT FORM
Office of Civil Rights (S/OCR)
SECTION 1: COMPLAINANT CONTACT/PERSONAL INFORMATION
3. Home Address (street, city, state, zip code) 4. E-mail Address
5. Preferred Method of Contact
7. Are you a:
United States Citizen
SECTION 2: REPRESENTATIVE INFORMATION
8. Do you have a representative?
10. Representative's Name 11. Firm's Name (if applicable)
12. Representative's Address
13. Representative's Phone Number 14. Representative's Email Address
SECTION 3: COMPLAINT INFORMATION
15. Is this a recurring discriminatory act?
OMB Control No. 1405-0220
Estimated Burden: 60 minutes*
Yes No Federal Government Employee Yes No Legal Permanent Resident (LPR) Yes No
Department of State
Employee Contractor (specify name of company)
9. Is your representative an attorney?
If, yes, provide the most recent date of alleged discrimination.
17. Date the alleged act/event occurred.
18. You are alleging discrimination on which basis?
(check all that apply and explain in item 19.)
Inaccessible Technology (please identify equipment,
website, etc. and explain fully in item 19)
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PURPOSE: The information solicited on this form is used for processing complaints of discrimination under the statutes listed in the "Authorities"
section of this notice.
ROUTINE USES: To respond to requests from individuals and agencies outside the Department (such as the White House, Congress, and the Equal
Employment Opportunity Commission) regarding the status of a complaint. More information on the Routine Uses for the system can be found in the
System of Records Notice STATE-09, Records Maintained by the Office of Civil Rights.
DISCLOSURE: Providing this information is voluntary. Failure to complete this form may lead to a delay in processing of the complaint, or rejection of
the complaint due to an inadequate basis to continue processing.
PAPERWORK REDUCTION ACT STATEMENT
The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.) requires us to inform you that this information is being collected to ensure that your
complaint contains all the information required to process it fully. The Office of the Director for Civil Rights will use the information to process your
Response to this request is voluntary. The information you provide on this form will only be shared with persons who have an official need to know,
and will be protected from public disclosure pursuant to the provisions of the Privacy Act, 5 U.S.C. § 552a(b). The estimated time required to complete
this form is *60 minutes. You may send comments regarding the accuracy of this estimate and any suggestions for reducing the time for completion of
the form to the U.S. Department of State, Office of Civil Rights, 2201 C Street NW, Washington, DC 20520.
An agency may not conduct or sponsor, nor is a person required to respond to, a collection of information unless it displays a currently valid OMB
Office of Civil Rights (S/OCR)
Discrimination Complaint Form DS-4282
PRIVACY ACT STATEMENT( 5 U.S.C. § 552a)
AUTHORITIES: Collection of this information is authorized by Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d); and Sections 504 and 508 of
the Rehabilitation Act of 1973 (29 U.S.C. §§ 790-790f)
FILING DEADLINE: You must file your complaint no later than 180 days from the date you became aware of the alleged discrimination, unless the
Department has extended the filing deadline. Complaints sent by fax are considered filed on the date the complaint is received in S/OCR. Complaints
sent by email will be considered filed on the date the complaint is received and acknowledged by S/OCR. Complaints filed after the 180-day deadline
must include a "good cause" explanation for the delay. Examples of "good cause" include:
1. You could not reasonably have been expected to know of the discriminatory act within the 180-day period;
2. You were seriously ill or incapacitated; or
3. The same complaint was filed with another federal, state, or local agency and that agency failed to act on your complaint.
REPRISAL (RETALIATION) PROHIBITED: No officer, employee, or agent of the Department of State, including persons representing the Department
and its programs, shall intimidate, threaten, harass, coerce, discriminate against, or otherwise retaliate against anyone who has filed a complaint of
alleged discrimination or who participates in any manner in an investigation or other proceeding raising claims of discrimination.
PURPOSE: The purpose of this form is to assist you in filing a discrimination complaint. For help completing the form, you may call the following
telephone number: Voice/TTY: (202) 647-9295. You are encouraged, but not required, to use this form to file your complaint. If you instead choose to
write a letter, it must contain all of the information requested in this form and be signed by you or your authorized representative.
You may send your complaint by mail, e-mail, or FAX. The mailing address is: 2201 C Street, NW, Suite 7428, Washington, DC 20520. The e-mail
address is . The fax number is (202) 647-4969. We must have a signed copy of your complaint. If you send your form by
e-mail, be sure to attach the signed copy. Incomplete information or an unsigned form may delay the processing of your complaint.
DEPARTMENT POLICY: The Rehabilitation Act of 1973 and Department policy prohibit discrimination against an individual based on a disability.
S/OCR will determine if it has jurisdiction under the law to process the complaint. Reprisal that is based on prior civil rights activity is prohibited.
If S/OCR accepts the completed form, the information collected during the investigation will be used to process your complaint.
Disclosure is voluntary. However, failure to supply the requested information or to sign the form may result in dismissal of your complaint. If your
complaint is dismissed you will be notified. The information you provide in this complaint may be disclosed to outside parties where the DOS
determines that disclosure is: 1) relevant and necessary to the Department of Justice, the court or other tribunal, or the other party before such tribunal
for purposes of litigation; 2) necessary for enforcement proceedings against a program that DOS finds to have violated laws or regulations; 3) in
response to a Congressional office if you have requested that the Congressional office inquire about your complaint or; 4) to the United States Civil
Rights Commission in response to its request for information.
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