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DISCRIMINATION COMPLAINT FORM

  1. DISCRIMINATION COMPLAINT FORM

  2. Miami Oklahoma
  3. SECTION 1: COMPLAINANT CONTACT/PERSONAL INFORMATION

  4. SECTION 2: REPRESENTATIVE INFORMATION

  5. 7. Do you have a representative?*
  6. 8. Is your representative an attorney?*
  7. SECTION 3: COMPLAINT INFORMATION

  8. 14. Is this a recurring discriminatory act?*
  9. 17. You are alleging discrimination on which basis? (check all that apply and explain in item 19.)*
  10. By checking this box, *
  11. City of Miami, OK

    Discrimination Complaint Form

    Instructions

  12. 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: 918-542-6685. 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: 129 5th Ave. NW, Miami, OK, 74354. The e-mail address is cvanover@miamiokla.net. The fax number is 918-542-6346. 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.

    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 by the City of Miami Human Resources Director. Complaints sent by email will be considered filed on the date the complaint is received and acknowledged the HR Director. 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.

  13. CITY POLICY: The Rehabilitation Act of 1973 and City Policy prohibit discrimination against an individual based on a disability. The City of Miami 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 the City of Miami 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 City of Miami 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 City of Miami 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.

  14. REPRISAL (RETALIATION) PROHIBITED: No officer , employee , or agent of the City of Miami, including persons representing the City 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.

  15. 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. §§ 790-7901)


    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.


    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.

  16. 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 of Human Resources for the City of Miami will use the information to process your discrimination complaint.

    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 City of Miami Office of Human Resources 129 5th Ave. NW, Miami, OK, 74354.

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