Complaint Forms for Discrimination; Health Information Privacy Complaints

D EPARTMENT OF HEALTH AND HUMAN SERVICES OFFICE FOR CIVIL RIGHTS (OCR) DISCRIMINATION COMPLAINT
YOUR FIRST NAME			YOUR LAST NAME
     			     
HOME PHONE			WORK PHONE
(     )      			(     )      
STREET ADDRESS				CITY
     				     
STATE	ZIP		E-MAIL ADDRESS (If available)
     	     		     
Are you filing this complaint for someone else? Yes No
If Yes, against whom do you believe the discrimination was directed?
FIRST NAME			LAST NAME
     			     
I believe that I have been (or someone else has been) discriminated against on the basis of:
Race / Color / National Origin Age Religion Gender (Male/Female)
Disability Other (specify):		     
Who do you think discriminated against you (or someone else)?
PERSON/AGENCY/ORGANIZATION
     
STREET ADDRESS				CITY
     				     
STATE	ZIP		PHONE
     	     		(     )      
When do you believe that the discrimination took place? LIST DATE(S)
     
Describe briefly what happened. How and why do you believe that you have been (or someone else has been) discriminated against? Please be as specific as possible. (Attach additional pages as needed)
     
Please sign and date this complaint.
SIGNATURE				DATE
				     
Filing a complaint with OCR is voluntary. However, without the information requested above, OCR may be unable to proceed with your complaint. We collect this information under authority of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973 and other civil rights statutes. We will use the information you provide to determine if we have jurisdiction and, if so, how we will process your complaint. Information submitted on this form is treated confidentially and is protected under the provisions of the Privacy Act of 1974. Names or other identifying information about individuals are disclosed when it is necessary for investigation of possible discrimination, for internal systems operations, or for routine uses, which include disclosure of information outside the Department of Health and Human Services (HHS) for purposes associated with civil rights compliance and as permitted by law. It is illegal for a recipient of Federal financial assistance from HHS to intimidate, threaten, coerce, or discriminate or retaliate against you for filing this complaint or for taking any other action to enforce your rights under Federal civil rights laws. You are not required to use this form. You also may write a letter or submit a complaint electronically with the same information. To submit an electronic complaint, go to OCR’s web site at: www.hhs.gov/ocr/discrimhowtofile.html. To mail a complaint see reverse page for OCR Regional addresses.

The remaining information on this form is optional. Failure to answer these voluntary questions will not affect OCR’s decision to process your complaint.
Do you need special accommodations for OCR to communicate with you about this complaint? (Check all that apply)
Braille Large Print Cassette tape Computer diskette Electronic mail TDD
Sign language interpreter (specify language):		     
Foreign language interpreter (specify language):			     		Other:		     
If we cannot reach you directly, is there someone we can contact to help us reach you?
FIRST NAME				LAST NAME
     				     
HOME PHONE				WORK PHONE
(     )      				(     )      
STREET ADDRESS					CITY
     					     
STATE	ZIP			E-MAIL ADDRESS (If available)
     	     			     
Have you filed your complaint anywhere else? If so, please provide the following. (Attach additional pages as needed) PERSON / AGENCY / ORGANIZATION / COURT NAME(S)
     
DATE(S) FILED				CASE NUMBER(S) (If known)
     				     
To help us better serve the public, please provide the following information for the person you believe was discriminated against (you or the person on whose behalf you are filing). ETHNICITY (select one) RACE (select one or more)
Hispanic or Latino American Indian or Alaska Native Asian Native Hawaiian or Other Pacific Islander
Not Hispanic or Latino Black or African American White Other (specify):								     
PRIMARY LANGUAGE SPOKEN (if other than English)       How did you learn about the Office for Civil Rights? HHS Website / Internet Search Family / Friend / Associate Church / Community Org Lawyer / Legal Org Phone Directory Employer Fed / State / Local Gov Healthcare Provider / Health Plan Conference / OCR Brochure Other(specify):      
To mail a complaint, please type or print, and return completed complaint to the OCR Regional Address based on the region where the alleged discrimination took place.
Region I - CT, ME, MA, NH, RI, VT Office for Civil Rights, DHHS JFK Federal Building - Room 1875 Boston, MA 02203 (617) 565-1340; (617) 565-1343 (TDD) (617) 565-3809 FAX			Region V – IL, IN, MI, MN, OH, WI Office for Civil Rights, DHHS 233 N. Michigan Ave -Suite 240 Chicago, IL 60601 (312) 886-2359; (312) 353-5693 (TDD) (312) 886-1807 FAX			Region IX - AZ, CA, HI, NV, AS, GU, The U.S. Affiliated Pacific Island Jurisdictions Office for Civil Rights, DHHS 90 7th Street, Suite 4-100 San Francisco, CA 94103 (415) 437-8310; (415) 437-8311 (TDD) (415) 437-8329 FAX
Region II - NJ, NY, PR, VI Office for Civil Rights, DHHS 26 Federal Plaza - Suite 3313 New York, NY 10278 (212) 264-3313; (212) 264-2355 (TDD) (212) 264-3039 FAX			Region VI - AR, LA, NM, OK, TX Office for Civil Rights, DHHS 1301 Young Street - Suite 1169 Dallas, TX 75202 (214) 767-4056; (214) 767-8940 (TDD) (214) 767-0432 FAX
Region III - DE, DC, MD, PA, VA, WV Office for Civil Rights, DHHS 150 S. Independence Mall West - Suite 372 Philadelphia, PA 19106-3499 (215) 861-4441; (215) 861-4440 (TDD) (215) 861-4431 FAX			Region VII - IA, KS, MO, NE Office for Civil Rights, DHHS 601 East 12th Street - Room 248 Kansas City, MO 64106 (816) 426-7277; (816) 426-7065 (TDD) (816) 426-3686 FAX			Region X - AK, ID, OR, WA Office for Civil Rights, DHHS 2201 Sixth Avenue - Mail Stop RX-11 Seattle, WA 98121 (206) 615-2290; (206) 615-2296 (TDD) (206) 615-2297 FAX
Region IV - AL, FL, GA, KY, MS, NC, SC, TN Office for Civil Rights, DHHS 61 Forsyth Street, SW. - Suite 3B70 Atlanta, GA 30323 (404) 562-7886; (404) 331-2867 (TDD) (404) 562-7881 FAX			Region VIII - CO, MT, ND, SD, UT, WY Office for Civil Rights, DHHS 1961 Stout Street - Room 1426 Denver, CO 80294 (303) 844-2024; (303) 844-3439 (TDD) (303) 844-2025 FAX
Burden Statement Public reporting burden for the collection of information on this complaint form is estimated to average 45 minutes per response, including the time for reviewing instructions, gathering the data needed and entering and reviewing the information on the completed complaint form. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HHS/OS Reports Clearance Officer, Office of Information Resources Management, 200 Independence Ave., S.W., Room 531H, Washington, D.C. 20201.

HHS-699 (11/07) (BACK)