DISCRIMINATION COMPLAINT CONSENT/RELEASE FORM

Name: ______________________________________________________

Address: ____________________________________________________

Telephone Numbers: (Home) ______(Work) ________ (Cell) ___________

Email Address: _______________________________________________

As a Complainant, I understand that the Central Massachusetts Metropolitan Planning Organization (CMMPO) may need to disclose my name during the course of the complaint review process to persons other than those conducting the review, in order for the review to be thorough. I am also aware of the obligation of the CMMPO to honor requests under the Freedom of Information Act: I understand that it may be necessary for the CMMPO to disclose information, including personally identifying details, which it has gathered as part of the investigation of my complaint. In addition, I understand that as a Complainant I am protected by CMMPO policies and practices from intimidation or retaliation in response to my having taken action or participated in action to secure rights protected by nondiscrimination statutes and regulations enforced by the CMMPO.

Please check one of the following options below:

□ I GIVE CONSENT and authorization to the CMMPO to reveal, insofar as required for an effective investigation, my identity to persons at the organization identified by me in my formal complaint. I also authorize the CMMPO to discuss, receive, and review materials and information about me with appropriate administrators or witnesses for the purpose of investigating this complaint. In doing so, I have read and understand the information at the beginning of this form. I also understand that the information received will be used for authorized civil rights compliance activities only. I further understand that I am not required to sign this release, and do so voluntarily.

□ I DENY CONSENT and authorization to the CMMPO to reveal, in the course of its investigation of my discrimination complaint, my identity to persons at the organization identified by me in my formal complaint, other than those who will be conducting the investigation. I also deny consent to the CMMPO to disclose any information contained in this complaint to any witnesses I have mentioned in the complaint. In doing so, I understand that I am not authorizing the CMMPO to discuss, receive, and review materials and information about me from the same. In doing so, I have read and understand the information at the beginning of this form. I also understand that my decision to deny consent may impede the investigation of my complaint and may result in an unsuccessful resolution of my case.

Signature: ____________________________ Date: __________________

Please sign and submit complaint form, consent form, and any additional information to:

By Mail: Janet A. Pierce, Central Massachusetts Metropolitan Planning Organization, 1 Mercantile Place, Suite 520, Worcester, MA 01608

By Email: titleVIcoordinator@cmrpc.org