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Civil Rights

Procedures Manual For Processing External Complaints of Discrimination

APPENDIX A

HCR's Memorandum

Processing Complaints Filed Under Title VI of

the Civil Rights Act of 1964 (Title VI) and the Americans with Disabilities Act of 1990 (ADA)

Dated January 18, 2008 to Division Administrators/Assistant Division

Administrator with Attached Letter Dated March 22, 2006

Processing Complaints Filed Under Title VI and ADA

 

APPENDIX B
COMPLAINT FORM

Discrimination Complaint

Name Phone Name of Person(s) That Discriminated Against You
Address Location and Position of Person (If Known)
City, State, Zip City, State, Zip
Discrimination
Because of:
Box Race Box color Box National Origin Sex
Box Age Box Disability Box Retaliation
Date of Alleged Incident

Explain As Briefly And Clearly As Possible What Happened And How You Were Discriminated Against. Indicate Who Was Involved. Be Sure To Include How Other Persons Were Treated Differently Than You. Also Attach Any Written Material Pertaining To Your Case.

 

 

 

 

 

 

 

 

Signature Date

APPENDIX C
INVESTIGATIVE CASE FILE

Format for the Investigative Case File

The investigative case file will include the following:

A Table of Contents should be the first page of the investigative case file. This entry describes each section in the investigative case file and identifies each entry under each Tab.

Tab 1
Tab 2
Tab 3
Tab 4
Tab 5
Tab 6
Tab 7
Tab 8
Tab 9

APPENDIX C-1

INVESTIGATOR'S LOG
(Title VI and Section 504/ADA Complaints)

INVESTIGATIVE LOG

DATE ACTION INITIALS
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     
     

APPENDIX C-2
INFORMAL SETTLEMENT AGREEMENT
(Title VI/Section 504/ADA Complaints)

FEDERAL HIGHWAY ADMINISTRATION
U.S. DEPARTMENT OF TRANSPORTATION

_________________________________
Complainant
Case Number:
_________________________________
Respondent
_________________________________
 

INFORMAL SETTLEMENT AGREEMENT

IT IS HEREBY AGREED by and between (NAME) hereinafter referred to as the complainant, and the (NAME), herein after referred to as the respondent as follows:

Section One: Purpose

This agreement is made between the parties for the complete and final settlement of their claims, differences, and actions with respect to the matters described below.

Section Two: Description of Allegation

The complainant initiated the complaint of discrimination by a complaint filed on (Date). The complainant alleged that (STATEMENT OF ALLEGATION)

Section Three: Terms of Settlement

The complainant and the respondent enter into this agreement without any finding of discrimination having been determined. The parties agree to the following, which will resolve and settle all claims and issues arising from the above‑mentioned allegation:

1.____________________________________________________________________

2.____________________________________________________________________

3.____________________________________________________________________

  1. The parties agree that this settlement shall not constitute an admission of discrimination or violation of any provision of law on the part of the respondent.
  2. It is understood that if the respondent fails to fulfill or rescinds any provision of this agreement, the complainant, upon written request, shall be entitled to reinstate the matter for further processing from the point processing ceased.
  3. It is understood that if the complainant fails to comply with the responsibilities under the terms of the agreement, the agreement may be terminated and any subsequent complaint based on the same issues will be rejected or cancelled.
  4. The parties agree that this agreement constitutes the sole and complete understanding between them. No other promises or agreements shall be binding unless signed by the parties and made a part of this agreement.
  5. The parties agree that this settlement shall become effective on the date that the last signatory signs this agreement.
_____________________________________
Complainant
_______________________
Date
_____________________________________
Respondent
_______________________
Date

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Page last modified on May 18, 2012.
Federal Highway Administration | 1200 New Jersey Avenue, SE | Washington, DC 20590 | 202-366-4000