DEPARTMENT OF HEALTH & HUMAN SERYICES

Office of the Secretary

Washington, D.C. 20201

DISCRIMINATION COMPLAINT FORM (Copy to disk file, print, fill out, and mail to regional office or print directly from MOSAIC or other browser.

Complainant

Name of Injured Party(s)

Address:

City:

State & Zip Code:

Phone # with area code:

Complaint Filed by (self or Representatives' name:

Address:

City:

State & Zip Code:

Phone # with area code:

If you have a representative, would you like to send copies , of all future correspontence to that person (Place a check mark by Yes or No)?

• Yes
• No

Person or Entity who has discriminated against the complainant:

Name:

Address:

City:

State: & Zip Code:

Phone # with area code:

Complainant was discriminated against because of (check one or more):

• Race or color
• National Origin
• Sex
• Handicap
• Age
• Religion

Date when the alleged discrimination occurred?

Has this complaint been filed with this agency before (Place check mark by Yes or No)?

• Yes
• No

Has this complaint been filed with any other agency?

• Yes
• No

If Yes Check one or more:

• Federal agency and/or court
• State agency and/or court
• Local agency

Name of Agency (or Court Contact):

Address:

City:

State:

Zip Code:

Phone # with area code:

If this complaint has been filed with another Federal or state agency, has the agency issued a right to sue letter to the complainant (Place check mark by Yes or No)?

• Yes
• No

If yes, does the complainant intend to file suit?

• Yes
• No

or Has the suit been filed?

• Yes
• No

Does the complainant intend to file with another agency?

• Yes
• No

Agency:

Address:

City:

State & Zip Code:

Phone # with area code:

Date when complainant intends to file:

Have efforts been made to resolve this complaint through the internal grievance procedures at the institution or agency?

• Yes
• No

If yes, what is the status of the complaint (Add page(s) necessary to explain the status)?

Name of the person who is conducting the grievance procedure:

Title of the person who is conducting the grievance procedure:

Please describe the alleged discrimination and how it has affected the complainant ( add page(s) necessary for your explanation):

For what remedies is the complainant asking?

Has the complainant filed any other complaints with the Office for Civil Rights.

• Yes
• No

Whom were they filed against?

Name:

Address:

City:

State & Zip Code:

Phone # with area code:

Issue:

Date of filing:

Regional Office:

If OCR finds that it does not have jurisdiction over the complaint, I give OCR permission to refer this complaint to the appropriate agency.

• Yes
• No

Additional Comments: _______________________________________________________________________________

Signature: ____________________

Date: _______________________

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U.S. Department of Health & Human Services · 200 Independence Avenue, S.W. · Washington, D.C. 20201