City/Town: _______________________ State: _________ Zip: _____________
As a complainant, I understand that the MPO 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 MPO to honor requests under the Freedom of Information Act: I understand that it may be necessary for the MPO 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 MPO 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 that are enforced by the MPO.
□ I GIVE CONSENT and authorization to the MPO 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 MPO 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 MPO 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 MPO 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 MPO 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:
Mr. Richard A. Davey, Chair
Boston Region Metropolitan Planning Organization
State Transportation Building
10 Park Plaza, Suite 2150
Boston, MA 02116-3968