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Discrimination Complaint Log

Name of Entity:________________________________________________________

Persons are not required to respond to a collection of information unless it displays a currently valid OMB control number. Pursuant to 29 CFR § 37.37(c), completing this log is required to obtain or retain benefits under the Workforce Investment Act of 1998. The Department of Labor's Civil Rights Center will use the information to identify any patterns of discrimination that may exist within a particular program, and to ensure that individuals who file complaints alleging discrimination with the recipient are afforded due process in that the complaint is processed in a accordance with the nondiscrimination and equal opportunity provisions of the Workforce Investment Act of 1998 for complaint processing procedures. Average response time is estimated to be 3 minutes for each compliant entry. Send comments regarding this estimate or any other aspects of this collection of information to the U.S. Department of Labor, Office of the Assistant Secretary for Administration and Management, Civil Rights Center, Room N-4123, Washington, D.C. 20210. Please reference OMB control number 1225-0077 expiration date 5/31/2011.

Date of Complaint

Name of Complainant

Address of Complainant

Status of Complainant

DOL-funded Program

Date of the Alleged Discrimatory Incident

Grounds/ (Bases) of Complaint

Description/Issue of Complaint

Name of Respondent

Is Respondent a recipient? Yes or No

Disposition

Date of Disposition

ADR Yes or No