HHSA - Complaint of Discrimination

Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Program Type*
Case Number*
Phone Number*
I believe I have been discriminated against on the basis of:
National Origin Color Race Ancestry Ethnic Group Age*

National OriginColorRaceAncestryEthnic GroupAgeSexGender IdentityGender ExpressionSexual OrientationMarital StatusDomestic PartnershipMedical ConditionGenetic InformationReligionPolitical AffiliationDisabilityAny Other Applicable Basis

	Name Of Person Who Discriminated	Title	Date Of Occurrence	Place Of Occurrence Agency
Event 1
Event 2
Event 3

Describe in your own words what action(s) have happened to lead you to believe you have been discriminated against.*
Indicate what resolution you are seeking.*
I understand the above information is true and complete to the best of my knowledge and belief.

I do not give my consent for the release of my name or other personally identifying information. I understand that this complaint may not be investigated as a result of my refusal to give my consent for the release of information.
By signing this complaint, I am authorizing the CDSS Civil Rights Bureau (CRB) to reveal my identity and other personal information to persons at the organization or institution under investigation and to other Federal and State agencies in accordance with applicable federal and state laws and regulations. I hereby authorize CRB to receive material and information including, but not limited to applications, case files, personal records, and medical records. The material and information shall be used for authorized civil rights compliance and enforcement activities. I understand that I am not required to authorize this release and I do so voluntarily.
Signature*

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