NEW YORK STATE DEPARTMENT OF TRANSPORTATION OFFICE OF CIVIL RIGHTS EXTERNAL DISCRIMINATION COMPLAINT FORM The purpose of this form is to help any person interested in filing a discrimination complaint with the New York State Department of Transportation’s (NYSDOT) Office of Civil Rights. However, you may write a letter with the same information and sign it which would be sufficient. The discrimination laws enforced by NYSDOT prevent recipients of NYSDOT funds from threatening or retaliating against any person because they have taken action to secure their rights that are protected by law. Note: If the complaint is against NYSDOT you must file your complaint with the U.S. Department of Transportation Federal Highway Administration, 1200 New Jersey Avenue, S.E., Washington, D.C. 20590, and/or call them at (202) 366-1595. How did you learn about your right to file a discrimination complaint with the NYSDOT? __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Important: A red star (*) means the information is required in order for your complaint to be investigated. 1. * Your name and address. Name: _____________________________________________ Address: ___________________________________________ ____________________________________________ Home Telephone Number : ( ) ________________________________ Work Telephone Number :( ) __________________________________ 2. * The name of the person or company or NYSDOT program area that committed the alleged discrimination. Name: ___________________________________________ Address: _________________________________________ __________________________________________ Home Telephone Number: ( ) __________________ Work Telephone Number: ( ) __________________ 3. * Your discrimination complaint is based on (check the appropriate basis) Race/Color:_____ National origin:_____ Sex:_____Religion:_____Age:_____Disability:_____ 4. If you have an attorney helping you with this complaint, provide their contact information. Name: ________________________________________ Address: __________________________________________ Telephone Number: ( ) _______________________________ ______________________________________________________________________________________________ 5. * When and where did the alleged discrimination take place? Month ________ Day ________ Year _______ 6. * Complaints of discrimination must be filed within 180 days from the date of the alleged act. If the alleged act of discrimination you are filing for took place more than 180 days ago, please explain your delay for filing this complaint. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 7. * Please describe in detail what happened and state the reason(s) you believe you were discriminated against. _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 8. Provide the name of any person you would like the investigator to interview or contact for additional information regarding your complaint. Name Address Area Code/Telephone Number 1._________________________________________________________________________ 2._________________________________________________________________________ 3._________________________________________________________________________ 4._________________________________________________________________________ 5._________________________________________________________________________ 9. How would you like your complaint to be resolved? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ 10. Have you filed this discrimination complaint with another agency? Yes:____ No:____ If you checked “Yes”, provide the following information: a. Name of the agency where you filed your complaint. _____________________________________________ b. The date you filed your complaint. _________________________________________________ c. The case number assigned to your complaint. __________________________________________ d. The name of Investigator assigned your complaint. ______________________________________ e. Current status of your complaint with the other agency.___________________________________________ * We cannot process your complaint without your signature and the date. _______________________________________ _______________ Signature of Complainant Date 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 make a copy of your complaint form for your personal records then mail the original form to: New York State Department of Transportation Title VI Coordinator Office of Civil Rights 50 Wolf Road, 6th Fl. Albany, NY 12232 (518) 457-1129-Telephone (518) 485-5517-Fax COMPLAINANT CONSENT/RELEASE FORM I have read the Notice Of Complainant and Interview Rights and Privileges by the NYSDOT and by the Federal Highway Administration (FHWA). As a complainant, I understand that during an investigation it may become necessary for the NYSDOT or the FHWA to reveal my identity to persons in the organization under investigation. I am also aware of the obligations of the NYSDOT and the FHWA to respond to requests under the Freedom of Information Act (FOIA). I understand that it may be necessary for the NYSDOT or the FHWA to share information, including personal details collected as part of their complaint investigation. In addition, I understand that as a complainant I am protected by the NYSDOTs and by the FHWAs regulations from intimidation or retaliation for having taken action or participated in action to secure rights protected by non-discrimination statues enforced by the NYSDOT or the FHWA. CONSENT/RELEASE Please read both paragraphs below then circle your choice of CONSENT or CONSENT DENIED. I have read and understand the above information and authorize the NYSDOT or the FHWA to identify me to persons in the organization or institution under investigation. I authorize the NYSDOT or the FHWA to receive material and information about me important to the investigation of my complaint. 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 volunteer to do so. CONSENT I have read and understand the above information and do not want the NYSDOT or the FHWA to provide my identity to the organization under investigation, or to review, receive copies of, or discuss material and information about me, regarding their investigation of my complaint. I understand this choice could delay the investigation of my complaint and may result in the closing of the investigation. CONSENT DENIED ____________________________________ _____________ Signature Date Notice of Complainant and Interview Rights and Privileges and the Use of Personal Information If you file a complaint or if you cooperate with an investigation conducted by the NYSDOT or the FHWA you are given certain rights and protections. The following is an explanation of your rights and protections. - Any agency that receives federal funds can not force its employees to be represented by the agency’ s lawyer. An agency can not intimidate, threaten or discriminate against any employee who refuses to tell the agency what occurred during their interview. An employee has the right to be represented during an interview with the NYSDOT or with the FHWA. The representative can be the agency’s lawyer, the employee’s private lawyer, or any other person the employee has asked to be present. - Any agency that receives federal funds can not discriminate against any person because they have filed a complaint, testified, assisted or participated in any manner in an investigation, proceeding, or hearing conducted under the Department Of Justices (DOJ) jurisdiction, or has asserted rights protected by statutes DOJ enforces. Information collected from the complainant or other individuals which is kept in the NYSDOTs or in the FHWAs investigation files may be exempt from disclosure under the Privacy Act or under the Freedom of Information Act (FOIA) if release of such information would constitute an unnecessary intrusion of personal privacy. There are two laws governing personal information submitted to any Federal agency, including the Department of Justice (DOJI: The Privacy Act of 1974 (5 U.S.C. §552a), and the Freedom of Information Act (5 US. C§552). The Privacy Act protects individuals from misuse of personal information held by the NYSDOT and the Federal Government. The law applies to records that are kept and that can be located by the individuals name or social security number or other personal identification system. Persons who submit information to the State or Federal governments should know that: The NYSDOT is required to investigate complaints of discrimination on the basis of race, color, national origin, sex, disability, age and religion against recipients of Federal financial assistance. The NYSDOT is authorized to conduct reviews of Federally-funded recipients to assess their compliance with civil rights laws. Information collected by the NYSDOT is reviewed by authorized personnel in the agency. The collected information may include personnel records or other personal information. The NYSDOT staff may need to share information with persons outside the agency during the course of verifying facts or collecting new facts to develop a basis for making a civil rights compliance determination. The NYSDOT also may be required to reveal certain information to any individual who requests it under the provisions of the FOIA. Personal information will be used only for the specific purpose for which it was submitted. Except in the instances defined in the FHWA’s regulation 28 CFR Part 16, the NYSDOT and the FHWA will not release the information to any other agency or individual unless the person who provided the information submits a written consent. One of these exceptions is when release is required under FOIA. No law requires the individual filing a complaint to give personal information to the NYSDOT or the FHWA and no penalty will be placed on any individual filing a complaint or other individuals who deny request from the NYSDOT or the FHWA. However, if the NYSDOT or the FHWA fails to obtain information needed to investigate allegations of discrimination, it may be necessary to stop 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 the NYSDOT and the FHWA to exercise authority to exempt systems of records only in compelling cases. The NYSDOT or the FHWA may deny a person filing a complaint access to the files compiled during the agency investigation of their civil rights complaint against an agency that receives Federal financial assistance. Complaint files are exempt in order to aid negotiations between recipients and the FHWA in resolving civil rights issues and to encourage recipients to furnish information essential to the investigation. The NYSDOT and the FHWA do not reveal the names or other identifying information about any 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 the FOIA or the Privacy Act. The NYSDOT and the FHWA 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 the 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 State and Federal Government. Individuals may obtain items from many categories of records of the Government, not only materials that apply to them personally. The NYSDOT and the FHWA must honor requests under the FOIA, with some exceptions. The NYSDOT and the FHWA generally are 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. Any State or 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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