ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call [Number for Language Assistance Service] (TTY: [Number for TTY Service]).
Discrimination is Against the Law
[Your Organization] complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. [Your Organization] does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
[Your Organization]:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you need these services, contact [Compliance Officer's Title and Name]
If you believe that [Your Organization] has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: [Compliance Officer's Title and Name], [Your Address], [Compliance Phone Number], TTY: [Number for TTY Service], [Compliance Fax Number], [Compliance Officer's Email]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, [Compliance Officer's Title and Name] is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.