After you have been contacted by your State Agency, HCFA, or OCR, please return your response to this "Information Request Form" within 25 days from the date of this request to the U.S. Department of Health and Human Services Office for Civil Rights Address of Regional Office or HQ City, State and Zip Code of Regional Office or Headquarters Office listed at http://www.hhs.gov/ocr/pregrant/statesalpha.html.

If you have any questions, or need materials in alternate format (large print, braille, audio, etc.) you may call our office at Office's Telephone and TDD numbers. You may also contact our office at Office's FAX number and E-mail address. Our 24-hour Web-site resource is available to assist a facility to respond to our request. This address is http://www.hhs.gov/ocr. After reaching the OCR home page, the "Quick Index" select the Pre-grant link at http://www.hhs.gov/ocr/pregrant/indexpg.html.

Please submit all the data for numbers 1 through 9:

1. Data about the facility:
   1. Name of Facility ______________________________________________

   2. Address _____________________________________________________

                    _____________________________________________________

   3. Administrator's Name _________________________________________

   4. Contact Person's Name ________________________________________
      (If different from Administrator)

   5. Telephone _____________________       TDD ______________________

   6. E-mail _________________________      FAX ______________________

   7. Type of Facility _______________________________________________
      (e.g. Home Health Agency, Hospital, Skilled Nursing Facility, etc.)

   8. Corporate Affiliation ___________________________________________

   9. Reason for Application __________________________________________
      (Initial Medicare certification, change of ownership, etc.)

2. A signed copy of the form HHS-690, Assurance of Compliance
   (A copy should be kept by your facility and the two signed originals must be returned with your response to this information request.)

3. Data regarding your nondiscrimination policies and notices, including:
   (Please see Attachment A "Establishing Effective Nondiscrimination Policies and Notice Procedures" for help in creating or modifying a nondiscrimination policy.)
   1. A copy of your written notice(s) of nondiscrimination that provides for admission and services without regard to race, color, national origin, disability, or age. A copy of your EEO policy is not sufficient to address admission and services.

   2. A description of the methods used by the facility to disseminate its nondiscrimination notice(s) to participants, beneficiaries, and potential beneficiaries, employees, patients/residents, community organizations, and referral sources of the protection against discrimination assured them by Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, and the Age Discrimination Act of 1975. (Please submit copies of brochures or newspaper articles, if publication is one of the methods used.) Please describe methods used to provide this information to persons who have sensory impairments, and to persons who have Limited English Proficiency.

4. Data regarding your staff's communication with persons of national origin minority groups who are Limited English Proficient (LEP), including:
   (Please see Attachment B "How to Establish Effective Communication Procedures for Persons with Limited English Proficiency and for Persons with Impaired Hearing, Vision, or Speech" for help, if needed.)
   1. A description (or copy) of procedures used by your facility to communicate with persons who have limited English proficiency, including how you obtain qualified interpreters for such persons.

   2. Samples of all written material printed in a non-English language. (Notices, consent forms, waivers, description of services provided, explanation of procedures, etc.) If none are available, a description of how LEP beneficiaries are provided the same information as other beneficiaries.

5. Procedures used by your facility:
   1. To communicate information about available services, waiver of rights, or consent to treatment to persons with impaired sensory or speaking skills. (Please see Attachment B1).

   2. To disseminate information to patients/residents and potential patients/residents about the existence and location of your services and facilities that are accessible to persons with disabilities. (Please see Attachment C.)

6. Data regarding the available auxiliary aids which your facility provides to persons with impaired sensory, manual, or speaking skills:
   (Please see Attachment C "Section 504 Notice of Program Accessibility" for examples of auxiliary aids.)
   1. If your facility employs 15 or more persons, provide a description or copy of the procedures used to communicate effectively with hearing impaired, visually impaired or speech impaired persons including:
      (See Attachments B, B1, and B2.)
      1. the procedures used to obtain the services of qualified sign language interpreters.
      2. the procedures used to communicate with hearing impaired persons over the telephone.
      3. methods used to train patient-contact staff in effective ways to communicate with sensory impaired persons, including how to obtain and use auxiliary aids.
      4. a list of auxiliary aids available at no additional cost to the disabled person.

   2. If your facility employs fewer than 15 persons, your facility has a continuing obligation to ensure that qualified persons with disabilities are not denied services because of their disability. To meet this obligation, your facility should, on your initiative, examine the needs of sensory and speech impaired patients/clients and potential patients/clients. Based on the needs identified, such auxiliary aids can be made readily available. OCR regulations do not specifically require your facility to furnish auxiliary aids if the provision of such aids would significantly impair your facility's ability to provide benefits and services.

7. A copy of your facility's Section 504 self-evaluation. (OCR's request for this information has been approved by OMB No. 0990-0124.)
   (Please see Attachment D "Section 504 Self-Evaluation Information" for help.)

8. Data regarding other requirements under the Department's Section 504 regulations for recipients with 15 or more employees, including:
   1. The name/title and telephone number of the Section 504 coordinator.

   2. A copy or description of your facility's procedure for handling disability discrimination grievances.
      (Please see Attachment E "Section 504 Grievance Procedure" for help in creating a grievance policy.)

9. Regarding Age Discrimination Act data, including:
   1. A description or copy of any policy(ies) or practice(s) restricting or limiting admissions or services provided by your facility on the basis of age.

   2. If such a policy or practice exists, please submit an explanation of any exception/exemption that may apply. In certain narrowly defined circumstances, age restrictions are permitted.
      (Please see Attachment F and Age Discrimination Act regulations to determine if an exemption applies.)

After review, an authorized official must sign and date the certification below. Please ensure that complete responses to all information/data requests are provided to facilitate prompt processing of your facility's request for Medicare participation. Failure to provide the information/data requested may delay your facility's certification for funding.

Certification

I certify that the information provided to the Office for Civil Rights is true and correct to the best of my knowledge.

Signature of Authorized Official: _____________________________________________________________

Title of Authorized Official: _______________________________________       Date: _________________

     

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Date revised: October 30, 2003