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COMPLAINANT CONSENT/RELEASE FORM
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, which
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 - 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
NOTICE ABOUT INVESTIGATORY USES OF PERSONAL INFORMATION
NOTICE OF COMPLAINANT/INTERVIEWEE RIGHTS AND PRIVILEGES
Complainants and individuals who cooperate in an investigation, proceeding or hearing
conducted by DOJ are afforded certain rights and protections. This brief description will
provide you with an overview of these rights and protections.
- A recipient may not force its employees to be represented by the recipient's counsel
nor may it intimidate, threaten, coerce or discriminate against any employee who refuses
to reveal to the recipient the content of an interview. An employee does, however, have
the right to representation during an interview with DOJ. The representative may be the
recipient's counsel, the employee's private counsel, or anyone else the interviewee
authorizes to be present.
- The laws and regulations which govern DOJ's compliance and enforcement authority
provide that no recipient or other person shall intimidate, threaten, coerce or
discriminate against any individual because he/she has made a complaint, testified,
assisted or participated in any manner in an investigation, proceeding, or hearing
conducted under DOJ's jurisdiction, or has asserted rights protected by statutes DOJ
- Information obtained from the complainant or other individual which is maintained in
DOJ's investigative files may be exempt from disclosure under the Privacy Act or under the
Freedom of Information Act if release of such information would constitute an unwarranted
invasion of personal privacy.
There are two laws governing personal information submitted to any Federal
agency, including the Department of Justice (DOJ): The Privacy Act of 1974 (5 U.S.C. §
552a), and the Freedom of Information Act (5 U.S.C. § 552).
THE PRIVACY ACT protects individuals from misuse of personal information held by
the Federal Government. The law applies to records that are kept and that can be located
by the individual's name or social security number or other personal identification
system. Persons who submit information to the government should know that:
- DOJ is required to investigate complaints of discrimination on the basis of race,
color, national origin, sex, disability, age, and, in some instances, religion against
recipients of Federal financial assistance. DOJ also is authorized to conduct reviews of
federally funded recipients to assess their compliance with civil rights laws.
- Information that DOJ collects is analyzed by authorized personnel within the agency.
This information may include personnel records or other personal information. DOJ staff
may need to reveal certain information to persons outside the agency in the course of
verifying facts or gathering new facts to develop a basis for making a civil rights
compliance determination. Such details could include the physical condition or age of a
complainant. DOJ also may be required to reveal certain information to any individual who
requests it under the provisions of the Freedom of Information Act. (See below)
- Personal information will be used only for the specific purpose for which it was
submitted, that is, for authorized civil rights compliance and enforcement activities.
Except in the instances defined in DOJ's regulation at 28 C.F.R. Part 16, DOJ will not
release the information to any other agency or individual unless the person who supplied
the information submits a written consent. One of these exceptions is when release is
required under the Freedom of Information Act. (See below)
- No law requires a complainant to give personal information to DOJ, and no sanctions
will be imposed on complainants or other individuals who deny DOJ's request. However, if
DOJ fails to obtain information needed to investigate allegations of discrimination, it
may be necessary to close the investigation.
- The Privacy Act permits certain types of systems of records to be exempt from some of
its requirements, including the access provisions. It is the policy of DOJ to exercise
authority to exempt systems of records only in compelling cases. DOJ may deny a
complainant access to the files compiled during the agency investigation of his or her
civil rights complaint against a recipient of Federal financial assistance. Complaint
files are exempt in order to aid negotiations between recipients and DOJ in resolving
civil rights issues and to encourage recipients to furnish information essential to the
- DOJ does not reveal the names or other identifying information about an individual
unless it is necessary for the completion of an investigation or for enforcement
activities against a recipient that violates the laws, or unless such information is
required to be disclosed under FOIA or the Privacy Act. DOJ will keep the identity of
complainants confidential except to the extent necessary to carry out the purposes of the
civil rights laws, or unless disclosure is required under FOIA, the Privacy Act, or
otherwise required by law.
THE FREEDOM OF INFORMATION ACT gives the public access to certain files and
records of the Federal Government. Individuals can obtain items from many categories of
records of the Government --not just materials that apply to them personally. DOJ must
honor requests under the Freedom of Information Act, with some exceptions. DOJ generally
is not required to release documents during an investigation or enforcement proceedings if
the release could have an adverse effect on the ability of the agency to do its job. Also,
any Federal agency may refuse a request for records compiled for law enforcement purposes
if their release could be an "unwarranted invasion of privacy" of an individual.
Requests for other records, such as personnel and medical files, may be denied where the
disclosure would be a "clearly unwarranted invasion of privacy."
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