STATE OF MISSOURI
DEPARTMENT OF SOCIAL SERVICES
CIVIL RIGHTS CONTRACT COMPLIANCE
SELF ASSESSMENT FORM
In order to receive Missouri Medicaid reimbursement, you must comply with all applicable civil rights regulations in providing services to your patients/clients/residents.  This form is to assist you in determining if your facility is in compliance with applicable civil rights laws.  For more information on specific civil rights regulations and guidance on completing this form, visit the Medicaid Provider website at http://www.dss.mo.gov/dms.  
1. Has your Service Location (offices or facilities where you provide your services) been previously  evaluated for civil rights compliance by either the US Department of Health and Human Services or the Missouri Department of Social Services? 
Yes No 
  a. If yes, when and by whom?
    __________________________________________________________
  b. Did you retain a copy of the results of any such evaluation?
Yes No 
2. Do you operate under a business name? Yes No
  a. What is that business name?
    __________________________________________________________
3. You must maintain a list of all Service Locations.  Service Locations are those offices or facilities where you provide your services.  List all Service Locations by the name of the facility, street address (no PO boxes), city, state and zip code.Use additional sheets as necessary. 
   
 
 
 
 
 
 
   
 
 
 
 
 
 
4. Is your organization public (government-owned) or private? 
5. Is your business minority owned? Yes No 
6. Does your facility have any planning or advisory boards?
Yes No 
  a. If yes, are persons with disabilities members of these boards?
Yes No
  b. What steps have you taken to ensure that qualified disabled persons are not denied the opportunity to participate as members of your planning or advisory boards?  
   
 
7. Have you designated a Civil Rights Coordinator for your business? Yes No
  a. What is that individuals name?  
    ______________________________________________  
  b. How can that person be reached?  
    ______________________________________________  
 
8. Do you have a written policy for non-discrimination in providing services? Yes No
  a. Is the policy posted at your services site in a location accessible to clients?  (Click here for a MO Department of Social Services, Non-Discrimination in the Provision of Services poster.)  Yes No 
  b. How do you notify clientele of your non-discrimination policy?  
    ______________________________________________________________  
  c. How is staff trained on this particular policy?  
    ______________________________________________________________  
    ______________________________________________________________  
9. Do you have a complaint or grievance procedure for individuals who feel they have been discriminated against? Yes No
  a. What is that procedure?  
    ______________________________________________________________
    ______________________________________________________________
    ______________________________________________________________
  b. Is it in written form? Yes No
  c. How is your clientele notified of that procedure?  
    ______________________________________________________________
    ______________________________________________________________
  d. How is your staff trained on this procedure? Yes No
  e. If Staff is trained on this procedure, explain how.  
    ______________________________________________________________
    ______________________________________________________________
    ______________________________________________________________
10. Does your facility have a procedure in place to provide reasonable accommodations to individuals with disabilities that would allow them equal access to services? Yes No
  a. If so, describe this procedure.
    ______________________________________________________________
    ______________________________________________________________
    ______________________________________________________________
    ______________________________________________________________
11. In what type of setting do you provide services to your clients (i.e., client.s home, office, hospital)?
  ______________________________________________________________
12. How do you ensure that all of your services are available to persons with a disability?
  ______________________________________________________________
  ______________________________________________________________
  ______________________________________________________________
  ______________________________________________________________
  ______________________________________________________________
13. How do you ensure that your intake procedures are free from measures which would screen-out persons with disabilities?  
  ______________________________________________________________  
  ______________________________________________________________  
  ______________________________________________________________  
  ______________________________________________________________  
  ______________________________________________________________  
14. Do you have procedures to ensure that a drug or alcohol abuser, who is suffering from a medical condition, is not denied admission or treatment solely because of his or her drug abuse or alcoholism? Yes No
  a. If so, describe this procedure.
    ______________________________________________________________
    ______________________________________________________________
15. Does your facility post information or publish materials in languages other than English? Yes No
16. If not, how do you assure adequate communication with individuals who have limited English proficiency?
  ______________________________________________________________
  ______________________________________________________________
  ______________________________________________________________
17. Do you have auxiliary aids or assistive devices available to ensure services are provided to persons with disability (i.e., hearing, speech and visual impairments)?
Yes  No
  a. If so, what are those auxiliary aids or assistive devices?
  ______________________________________________________________
  ______________________________________________________________
  b. If you do not have auxiliary aids or assistive devices, what other resources do you use to ensure persons with disabilities receive services? 
  ______________________________________________________________
  ______________________________________________________________
18. How are staff members trained to respond to clients requesting or needing auxiliary aids or assistive devices?
  ______________________________________________________________
  ______________________________________________________________
  ______________________________________________________________
  ______________________________________________________________
19. Does your office/facility provide transportation to your clients?
Yes No
  a. If yes, what provisions are made to accommodate persons with disabilities?
    ______________________________________________________________
    ______________________________________________________________
20. Do you or your office/facility enter into agreements/contracts through which another office/facility provides services to your patients/clients/residents?
Yes No
  a. How do you ensure that those subcontractors are not excluding individuals with disabilities? 
Yes No
  b. Do you have a copy of their non-discrimination policy and complaint procedure? Yes No
21. Do you employ more than 15 people? Yes No
  If yes , you must answer question 21 a-g. 
  a. How do your notify applicants and employees that you do not discriminate?
  b. How do you ensure that applicants and employees with impaired hearing or vision are given notice of your non-discrimination policy?
  c. Do your job advertisements include information that you are an equal opportunity employer? Yes No
  d. Do you have a policy regarding the provision of reasonable accommodations for applicants and employees? Yes No
  e. If yes, do you have adequate procedures to ensure documentation of decisions regarding refusal to hire or promote because of undue hardship? Explain the procedure.
    ______________________________________________________________
    ______________________________________________________________
    ______________________________________________________________
  f. Have you reviewed the physical and mental requirements of the primary duties of each of your jobs to ensure that no criteria are included that would discriminate against disabled persons unless such criteria are specifically necessary? Yes No
  g. Is your employment application form and hiring process/interview questionnaire devoid of questions regarding disability? Yes No
22. Have you reviewed your facility or business policies regarding employee actions (hiring, recruiting, layoffs, etc) to ensure that those policies do not exclude individuals with disabilities?
Yes No
23. Is your office/facility location accessible to all individuals (clients and employees) with disabilities?
Yes No 
  a. If your office/facility location is not accessible, how do you ensure that individuals with disabilities have access to your services?
    ______________________________________________________________
    ______________________________________________________________
24. If you are planning structural changes, will you ensure that a transition plan is developed to identify methods you will use to ensure program accessibility?
Yes No 
  a. Are you aware of the requirement for barrier free design in new construction and major alteration?
Yes No 
25. Do you retain documents as required by federal and state regulations and your contractual agreements?
Yes No