(TYPE ON YOUR FACILITY
BUSINESS LETTERHEAD)
Complaint/Grievance
Procedure
This
policy statement complies with the Civil Rights Act, Title VI [45 CFR part 80.7
(b)] and section 504 of the Rehabilitation Act of 1973 [45 CFR part 84.7 (b)].
If you feel that you have been denied a benefit or service because of your
race, color, national origin, age, sex, religion or disability you may file a
Complaint of Discrimination with the Facility Administrator of (Name
of provider), either verbally or in writing. A written response will be issued to you
within 15 days of the complaint notice.
(It is recommended a written response be issued to the complaining party
within 15-30 days after the complaint is filed with your facility).
You may also file a complaint with one of the external agencies listed below. If you choose to file your complaint in writing, you must include your name, address, telephone number and a brief description of what occurred which led you to believe you were discriminated against. If you need assistance, the Facility Administrator of (Name of Provider) will be available to assist you. You may also file a complaint by calling either of the external agencies. Please note that the Department of Social Services has a toll-free number in addition to a TDD number.
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Department
of Social Services
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Dept.
of Health and Human Services
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Office
of Civil Rights
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Office
of Civil Rights
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P.O.
Box
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(816)
426-7277
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(800)
776-8014 or (800) 877-6916 (TDD)
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Non
Retaliation Clause: You will not be intimidated,
harassed, threatened or suffer any penalty because you file a complaint. Any penalty or reprisal against you or any
other involved persons is prohibited by law.