SERVICE DELIVERY OR EMPLOYMENT DISCRIMINATION COMPLAINT

SERVICE

Children and Families

DCF-F-'156-E

DELIVERY OR EMPLOYMENT

Health Services

F-001 66

DISCRIMINATION COMPLAINT

Workforce Development

DETS-'1 6707-E (R. 1212013)

lf you need this form ease contact:

Name - Equal Opportunity Coordinator Phone (TDD)

()

Name of Complainant Phone

()

Basis for Service Delivery or Employment Discrimination Complaint: ln service delivery, discrimination is

prohibited on the following basis: age, color, disability, national origin, religion, political belief or affiliation , marital

status, familial or parental status, race, sex, gender identity, sexual orientation, genetic testing, or all or part of an

individual's income is derived from any public assistance program, retaliation for filing a complaint, or for assisting

with a complaint, opposing discrimination in a program, service or activity conducted or funded with federal

assistance.

Employment discrimination is prohibited on the basis of: age (over 40), national origin or ancestry, arrest record,

conviction record, color, creed or religion, disability or association with a person with a disability, genetic testing,

honesty testing, marital status, pregnancy or childbirth, military service, race, sex, sexual orientation, use or non

use of lawful products off the employer's premises during non-working hours. Employees may not be harassed in

the workplace based on their protected status nor retaliated against for filing a complaint, for assisting with a

complaint, or for opposing discrimination in the workplace. The Federal Health Care Provider Conscience

Protection Laws prohibit recipients of certain federal financial assistance from discrimination against health care

providers because of the provider's refusal or willingness to participate in sterilization procedures or abortions

contrary to or consistent with the provider's religious beliefs or moral convictions. These protections apply to

employment and service delivery; however, not all prohibited bases will apply to all programs and/or employment

activities.

Name of the Agency and/or Employee or Employer Against Whom the Complaint is Filed.

Describe the action or treatment that you think was discriminatory. lnclude information about who, what, when,

where, how, why, and the names, addresses and phone numbers of any witnesses, if you know them. Please be

specific about the date of the last incident. You may write this on another sheet of paper if you need more room.

ln the space below, please say how many pages are attached, if you need to add pages.

Description of the Relief or Satisfaction you Want:

Phone (Voice)

()

Address (number, street, city, state, zip code)

SIGNATURE - Complainant or Complainant Representative

Co-authored by: Departments of Children and Families, Health Services; and Workforce Development

Page 1 of 5

Page 2

The information below is to be completed by the person at the agency who receives your complaint, looks into

it and responds to you.

INFORMAL COMPLAINT

Date Received

Agency

Actions and lndividual(s) to be lnvestigated:

Findings (Must be completed within 30 days):

Action Taken:

Further Action Required? n Yes n uo

lf yes, what action is recommended?

Children and Families

DCF-F-156-E

Health Services

F-00166

Workforce Development

DETS-,16707-E

Page 3

HOW TO FILE AN EMPLOYMENT OR SERVICE DELIVERY DISCRIMINATION COMPLAINT

lnstructions for Completing Employment or Service Delivery Discrimination Complaint

lf you feel that you have been treated differently because of your age, race, religion, color, sex, national

origin or ancestry, disability or association with a person with a disability, arrest or conviction record, sexual

orientation, marital status or pregnancy, political belief or affiliation, military participation, or use or non use

of lawful products off the employer's or service provider's premises during non-working hours, you may file

a complaint. lf you were wrongfully denied services, or if the treatment you received was separate or

different from others, or if the program was not accessible to you, it may be discrimination.

IMPORTANT: lf your application for service was not taken or your were told you were not eligible for a

particular program, BUT you feel you are eligible, ask the provider for a pamphlet which explains how to

request a local agency appeal process or State administrative hearing review. Your right to appeal a

decision or to request a State administrative hearing does not need to be connected to a discrimination

complaint.

You may file an informal discrimination complaint with your employer or service provider, or you may file a

formal discrimination complaint with a state or federal agency. Complaints alleging discrimination on the

basis of age in programs funded by U.S. Department of Agriculture, Food and Nutrition Services (USDAFNS)

must be filed directly with the USDA Office of Adjudication, 1400 lndependence Avenue, S.W.,

Washington D.C. This complaint will be forwarded to the appropriate FNS Regional OCR within five (5)

working days after receipt. No one may threaten or harass you for making a complaint. No one may

threaten or harass your witnesses because they are willing to say what they saw, heard or experienced.

Complaints filed under the Federal Health Care Provider Conscience Protection Laws must be filed directly

with HHS Office of Civil Rights.

All formal complaints must be filed within 180 days of the event or treatment you feel was discrimination. ,

However, you should file the complaint as soon as possible after the action took place. lF you file an

informal complaint and you are not satisfied with the resolution, you can still file a formal complaint as long

as you do it within filing time frame. Do not wait until after the filing deadline to get an answer to the

informal complaint if you plan to make a formal complaint.

To file an informal discrimination complaint with your provider or employer, request a discrimination

complaint form by calling the Equal Opportunity Coordinator at or TDD

Send the completed form back to your provider's Equal Opportunity Coordinator. His or her name should

be on this form.

lf you wish to file a formal discrimination complaint, you may send the completed complaint form directly to

the appropriate state or federal agency listed on the following pages. lnclude a letter stating that you are

making a formal complaint to their agency as the funding source. Staff of the state or federal agency will

provide the results to you within 90 days.

Children and Families

DCF-F-156-E

Health Services

F-00166

Workforce Development

DETS-16707-E

Page 4

File formal discrimination complaints about these services with the state agency listed below.

PROGRAM STATE AGENCY

Wisconsin (Wl) Works (W-2), (W-2) Transitions, Temporary

Assistance to Needy Families (TANF), Brighter Futures

lnitiative, Child Support, Early Care and Education, Head

Start, Child Care and Day Care Certification Programs, Child

Welfare, Milwaukee Child Welfare and lntegration Programs,

Emergency Assistance, Families and Economic Security,

Community Service Jobs, Job Access Loans, Adoption and

Foster Care Programs, Safety and Permanence Programs

(Out-of-Home Care, Safety and Well Being, Program lntegrity),

Child Placement Services, Child Abuse and Neglect,

Protective Services, Kinship Care, Domestic Abuse/Domestic

Violence Programs, and other programs administered by the

Wl Department of Children and Families. Refugee and

lmmigrant Services (Social Services, Older Refugee, Family

Strengthening, Health Services, Preventative Health Services,

Mental Health, Refuqee Cash and Medical Assistance)

Wl Department of Children and Families

201 E. Washington Ave, Second Floor

P.O. Box 8916

Madison, Wl 53708-8916

608-266-5335 (voice)

800-864-458s (TTY)

Medical Assistance Services, Medicaid, Badger Care Plus,

Food Share (formerly Food Stamps Program in Wisconsin),

TEFAP, Senior Care, Community Aid, Long Term Care, Mental

Health and Substance Abuse, Services to the Deaf and Hard

of Hearing, Blind and Visually lmpaired and Persons with

Disabilities, Family Care, Public Health Services, Community

Health Center Programs, WIC (Women, lnfants and Children),

and other programs administered by the Wl Department of

Health Services

Wl Department of Health Services

Office of Affirmative Action and Civil Rights

Compliance

1 W. Wilson, Room 656

P.O. Box 7850

Madison, Wl 53707

608-266-9372 (voice)

608-266-0583 (fax)

888-701-1251 (TTY) or Wisconsin Relav 711

Wisconsin Workforce lnvestment Act, and other programs

administered by the Wisconsin Department of Workforce

Development.

Wl Department of Workforce Development

ATTN: Equal Opportunity Officer

201F-. Washington Ave, Room G100

P.O. Box7972

Madison, Wl 53707-7972

608-266-6889 (voice): 866-27 5-1165 (TDD)

Unsubsidized and Trial Jobs Complaints. Any employment

condition as an employee of DCF, DHS and/or DWD funded

entities and their subcontractors.

Equal Rights Office

P.O. Box 8928

Madison, Wl 53708

608-266-6860 (voice)

'.608-264-8752 (TDD)

Equal Rights Office

819 North Sixth Street, Room 255

Milwaukee, Wl 53203

41 4-227 -4384 (voice); 41 4-227 -4081 (TDD)

U.S. Equal Employment Opportunity

Commission

Reuss Federal Plaza

310 West Wisconsin Ave., Suite 800

Milwaukee, Wl 53203-2292

800-669-4000 (voice)

41 4-297 -4133 (fax); 800-669-6820 (TTY)

Milwaukee District Office

U.S. Department of Labor, OFCCP

Federal Building

310 West Wisconsin Avenue, Suite '1 1 15

Milwaukee, Wl 53203

41 4-297 -382 1 (voice), 41 4-297 -4038 (fax)

Children and Families

DCF-F-156-E

Health Services

F-00166

Workforce Development

DETS-16707-E

Page 5

You also have the right to file a formal complaint with a federal agency listed below.

PROGRAM FEDERAL AGENCY

Formal Discrimination Complaints about any of the

above services administered by the Wisconsin

Department of Health Services.

Formal Discrimination Complaints filed based on the

Federal Health Care Providers Conscience Protection

Law.

Office for Civil Rights

U.S. Department of Health and Human Services

200 lndependence Avenue, SW

Room 509F, HHH Building

Washington, D.C.20201

800-368-1 019 (voice, toll free)

800-537-7697 (TDD toll free)

U.S. Dept. of Health and Human Services

Office for Civil Rights - Region V

233 N. Michigan Ave., Suite 240

Chicago, lL 60601

800-368-1019 (voice, toll free)

312-886-1807 (fax)

800-537-7697 (TDD, toll free)

Formal Discrimination Complaints about any program

receiving federal assistance.

Coordination and Review Section - NWB

Civil Rights Division

U.S. Department of Justice

950 Pennsylvania Avenue, NW

Washington, D.C. 20530

888-848-5306 - English and Spanish (ingles y español)

202-307-2222 (voice)

202-307-2678 (TDD)

Title Vl Hotline:

1-888-TITLE-06 (1-888-848-5306) (Voice / TDD)

Disability Complaints:

U.S. Department of Justice

Civil Rights Division

950 Pennsylvania Avenue, NW

Disability Rights Section - NYAV

Washington, DC 20530

800-514-0301 (voice)

800-514-0383 (TTY) (also in Spanish)

lf you wish to file a Civil Rights Program of

Discrimination with the USDA for the Supplemental

Nutrition Assistance Program (SNAP) (Formerly known

as the Food Stamp Program at the Federal level)

FoodShare (Formerly known as the Food Stamps in

Wisconsin), WlC, TEFAP and the Food Stamp

Employment and Training (FSET) Program complete

the USDA Program Discrimination Complaint found

online at:

http://www.ascr.usda.qov/complaint filing cust.html, or

USDA Director, Office of Adjudication

1400 lndependence Avenue, SW

Washington, D.C. 20250-941 0

866-632-9992 (request a form)

Email: program. intake@usda. gov

800-877-8339 (Federal Relay Services)

800-845-6 1 36 (Spanish)

at any USDA office, or call 866-623-9992 to request a

form.

Children and Families

DCF-F-156-E

Health Services

F-001 66

Workforce Development

DETS-16707-E

Children and Families

DCF-F-157

COMPLAINANT CONSENT / RELEASE

Health Services

F-00167

Workforce Development

DETS-'16708-E (R.12t1t2013)

Complainant's Name Date Completed

Address Zip Code

Telephone Number Email Address

Please read the information below, initial the appropriate space, sign and date this form.

I have read the Notice of lnvestigatory Uses of Personal lnformation by DCF, DHS or DWD. As a

complainant, I understand that in the course of a preliminary inquiry or investigation it may become

necessary for DCF, DHS or DWD to reveal my identity to persons at the organization or institution under

investigation. I am also aware of the obligations of DCF, DHS or DWD to honor requests under the

Freedom of lnformation Act. I understand that it might be necessary for DCF, DHS or DWD to disclose

information, including personally identifying details, which it has gathered as a part of its preliminary inquiry

or investigation of my complaint. ln addition, I understand that, as a complainant, I am protected by federal

regulations from intimidation or retaliation for having taken action or participated in an action to secure

rights protected by nondiscrimination statutes enforced by the federal government.

CONSENT / RELEASE

CONSENT GRANTED - I have read and understand the above information and authorize DCF, DHS or

DWD to reveal my identity to persons at the organization or institution under investigation and to other

federal agencies that provide federal financial assistance to the organization or institution or also have civil

rights compliance oversight responsibilities that cover that organization or institution. I hereby authorize

DCF, DHS or DWD to receive material and information about me pertinent to the investigation of my

complaint. This release includes, but is not limited to, applications, case files, personal records, and or

medical records. I understand that the material and information will be used for authorized civil rights

compliance and enforcement activities. I further understand that I am not required to authorize this release,

and I do so voluntarily. Place your lnitials on this line if you give consent. (lnitials).

CONSENT DENIED - I have read and understand the information and do not want DCF, DHS or DWD to

reveal my identity to the organization or institution under investigation, or to review, receive copies of, or

discuss material and consent information about me, pertinent to the investigation of my complaint. I

understand that this is likely to make the investigation of my complaint and getting all the facts more difficult

and, in some cases, impossible, and may result in the investigation being closed. Place your lnitials on this

line if you do not give consent: (lnitialst.

Cell Phone Number

Program(s) for which this Consent / Release form applies

SIGNATURE - Complainant or Complainant Representative Date Signed (mm/dd/yyyy)

Co-authored by: Departments of Children and Families, Health Services; and Workforce Development

Page 1 of 1