Free F-80983A - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Enterprise Services F-80983A (04/09)

STATE OF WISCONSIN

INSTRUCTIONS COMPLETING THE CIVIL RIGHTS COMPLAINT FORM
Title VI of the 1964 Civil Rights Act requires non-discrimination based on national origin. Program and physical access for persons with disabilities is covered in the American with Disabilities Act of 1990 and the Rehabilitation Act of 1973 as amended, Section 504. If 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. If you feel that you have been treated differently because of your race, color, national origin or limited English proficiency, age, gender, disability, religion or retaliation, you may file a complaint. You may also file a discrimination complaint based on political affiliation if you are eligible for the Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps, or known in Wisconsin as the FoodShare Program (FoodShare Wisconsin). You may file an informal discrimination complaint with your service provider, or you may file a formal discrimination complaint with a state or federal agency. Any consumer of the Wisconsin Department of Health Services (DHS) services and benefits funded by the U.S. Department of Health and Human Services (DHHS) may file a civil rights complaint at any time with the Wisconsin DHS Affirmative Action and Civil Rights Compliance (AA/CRC) Office. You may also file a discrimination complaint with the US DHHS Office for Civil Rights, Region V. Any complaint about the Supplemental Nutrition Assistance Program (FoodShare Wisconsin), WIC or The Emergency Food Assistance Program (TEFAP) can be filed with the Wisconsin DHS, AA/CRC Office or directly with the U.S. Department of Agriculture (USDA). All formal complaints must be filed within 180 days of the alleged discriminatory act; however, you should file the complaint as soon as possible after the action took place. If you file an informal complaint with your service provider and you are not satisfied with the resolution, you can still file a formal complaint as long as you do it within the time frame indicated. SECTION I ­ COMPLAINANT Provide your name, address, telephone number and other contact information as requested. Filing date is the date you complete, sign and mail this complaint form. SECTION II ­ RESPONDENT / PROVIDER INFORMATION Provide the name of the agency that you believe discriminated against you. In this section, you may also complete the name(s) of the individual(s) whom you believe discriminated against you and the agency or recipient that employs that/those individual(s). SECTION III ­ REASON FOR DISCRIMINATION Check the box(es) that you believe was the source of the discriminatory act you experienced because of your race, color, national origin, gender, religion, age, disability or if it is a retaliation in response to an action that you have reported SECTION IV ­ DISCRIMINATION STATEMENT Describe the incident that occurred, or the action that was taken by the individual(s) or agency that discriminated against you. Explain as clearly as possible what happened, why you believe it happened and how you were discriminated against. If applicable, please include how other persons were treated differently from you. If you have documents to support your description of the discrimination that you are reporting, provide a copy of the supporting documents.

SECTION V ­ CERTIFICATION AND SIGNATURE Self Explanatory

SECTION VI ­ MAILING YOUR COMPLAINT 1. At the State Level To file a formal discrimination complaint about Medical Assistance Service, Women, Infants and Children, the Supplemental Nutrition Assistance Program (FoodShare Wisconsin), BadgerCare, SeniorCare, Child Placement Services, Medicaid, Community Aid and other programs within the Wisconsin Department of Health Services (DHS) jurisdiction, complete the Civil Rights Complaint Form (F-80983) and mail to: Wisconsin Department of Health Services Division of Management and Technology Office of Affirmative Action and Civil Rights Compliance P.O. Box 7850 Madison, WI 53707 Voice: 608-266-9372, TTY: 1-888-701-1251 Email: [email protected] 2. At the Federal Level To file a formal discrimination complaint about any of the services administered by the Wisconsin Department of Health Services mentioned above, write or call: U.S. Department of Health and Human Services Office for Civil Rights-Region V 233 N. Michigan Ave. Chicago, IL 060601 Telephone: 312-886-2359, TTY: 315-353-5693 To file a formal discrimination complaint about the Supplemental Nutrition Assistance Program (FoodShare Wisconsin), WIC or The Emergency Food Assistance Program (TEFAP), write or call: USDA Director, Office of Civil Rights Room 326-W, Whitten Building 1400 Independence Ave, S.W. Washington, D.C. 20250-9410 Telephone: 202-720-5964 Or USDA, Regional Civil Rights Office 77 Jackson Boulevard, 20th Floor Chicago, IL 60604 Telephone: 312-353-1457