Client Complaint or Report of Discrimination Form - PDF

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Oregon Department of Human Services

Client Complaint
or
Report of Discrimination Form

If you need help communicating with the Department of Human Services
(DHS) let your case worker or counselor know. They can provide this form
in an “alternate format” such as large print, audio tape, Braille, or other
languages.
Do you need any of the following to communicate with us?

 Braille  Large print  Audio tape  Computer diskette
 E-mail  TTY  American Sign Language interpreter
 Foreign language interpreter - language: __________________________

For DHS use only:
Date complaint received:_____________ Complaint received by: ______________

Copies provided to client?  Yes  No
Remove the instruction pages. Attach a DHS 170A Review Sheet (available from the DHS Forms
Server). Send discrimination reports to: Civil Rights Investigator, 500 Summer N.E. E-17, Salem,
Oregon 97301-1097. Other complaints go to the appropriate Line Supervisor.

DHS 0170 (02/2005) Replaces all previous Client Complaint forms
DHS Client Complaint or Report of Discrimination Form

Instructions
Please talk with your worker or a line supervisor if:
• You have a complaint about DHS customer service or
• You think DHS discriminated against you or
• You think your personal information was not kept conﬁdential

If that doesn’t solve the problem
• Fill out the attached form or call:
the Governor’s Advocacy Ofﬁce (1-800-442-5238)

Do not use this form if:
• You have a complaint because your beneﬁts were denied, re-
duced or ended.
If your beneﬁts were denied, reduced or ended you must ﬁll out the
Administrative Hearing Request Form (DHS 443).

You can get the Administrative Hearing Request Form at a DHS ofﬁce
or from the DHS web site at: www.dhsforms.hr.state.or.us or you can
call the Governor’s Advocacy Ofﬁce at 1-800-442-5238.

• If you disagree with an action taken in a Vocational Rehabilita-
tion or Child Welfare program, please contact your local ofﬁce
and ask how to appeal your case.

How to ﬁle a complaint
• Use this form to ﬁle your complaint within 60 days after the problem
occurred. Mail it or turn it in to any DHS ofﬁce. That ofﬁce can also
help you complete the form.
Or
• The Governor’s Advocacy Ofﬁce will take your complaint by phone
(1-800-442-5238). You can call the same phone number to get help
from the DHS Americans with Disabilities Act Coordinator or Civil
Rights Investigator to ﬁle a discrimination complaint.

1
DHS Client Complaint or Report of Discrimination Form

1 Name of person with the complaint: ____________________________________
Last 5 digits of complainant’s social security number: ______________________
Mailing Address: ___________________________________________________
_________________________________________________________________
Home Phone::((____) ______________ Work Phone: (____) _______________
TTY/Message Phone: (_____) __________________

2 Complete this section if you are ﬁlling this form out for someone else
Your Name: _______________________________________________________
Your Mailing Address: _______________________________________________
_________________________________________________________________
Your Home Phone:.(___) _____________ Work Phone: (____) ______________

3 Please mark the reason for your complaint:

 You did not receive good customer service from DHS.

 Personal information about you was not kept conﬁdential by DHS.

 You believe you were discriminated against because of:

 Age  Gender  Race, color, or national origin  Religion
 Political beliefs  Disability  Sexual orientation
 Other: ______________________________________________

4 Details about your complaint
A. Describe what happened. When did it happen? Who was involved? Attach
copies of any papers that might help us review your complaint.
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

If you need more space, attach sheets of paper
(Continue on next page >>)
2
DHS Client Complaint or Report of Discrimination Form

Details about your complaint (continued)

ocation
B. Location of the DHS ofﬁce you visited.
_________________________________________________________________
_________________________________________________________________
If you need more space, attach sheets of paper

C. What services were you requesting or receiving?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
If you need more space, attach sheets of paper

D. What would you like done to resolve your complaint?
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
If you need more space, attach sheets of paper

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Your Signature:_________________________________ Date: _____________
(Signature not required if taken by phone)

I give DHS permission to speak to the representative ﬁling this complaint on my be-
alf.
alf
half.
Federal law protects people who ﬁle complaints from being treated badly or discrimi-
nated against because of it.
3
DHS Client Complaint or Report of Discrimination Form

About customer service and conﬁdentiality complaints
Good customer service and keeping client information conﬁdential is important to DHS.
You have the right:
• To get accurate and complete information
• Be treated politely and have your questions answered
• Be treated fairly and respectfully
• Be told about DHS programs or beneﬁts
• Have your calls returned in a reasonable time*
• Have your beneﬁts or changes processed in a reasonable time*
• Be communicated with in a way that meets your needs
• Have personal information about your case kept conﬁdential
• Have your health-care information kept conﬁdential
• To ﬁle a complaint if you feel you were not treated fairly

* Each DHS program has its own standards for what is a “reasonable time.”
Workers will try to return calls within one or two working days. But that may not be
possible if the worker is out of the ofﬁce or in court hearings.

About discrimination complaints

U.S. civil rights laws and DHS policies state that people cannot be treated differently
because of their:
• Age • Race, color or national origin • Gender • Religion • Political beliefs
• Disability • Sexual orientation

Please note: Discrimination based on sexual orientation is not protected by U.S. civil
rights laws. However, it is covered by DHS policies.
You have the right to ﬁle a discrimination complaint if someone from DHS:
• Does not provide you equal service and beneﬁts because of the above reasons
• Does not communicate with you in an “alternate format” if requested
• Does not have facilities that are accessible to you
• Does not allow clients with disabilities to take part in programs and services

What happens after you ﬁle a complaint?
If your complaint is about customer service or failure to keep your information conﬁden-
tial, it is sent to a line supervisor for review.
The supervisor will contact you as soon as possible but within ﬁve business days of get-
ting the complaint. (It may take more time to contact you if you do not have a phone.)
At that time, the supervisor may set up a meeting with you to try and solve the matter.
(Continued on next page >>)
4
DHS Client Complaint or Report of Discrimination Form

The meeting could be in person or over the phone. You can have someone with you
at the meeting to help you. You can bring copies of papers relating to the problem.
If your complaint is about an employee, that person will be told and they will have a
chance to write a response to your complaint and may or may not attend the meeting.
At the meeting you can explain your complaint. You should make notes in advance so
you can talk about it clearly and calmly. Ask the supervisor to explain things in the
meeting that you don’t understand.
If the complaint can’t be resolved at this meeting, other managers will review it, and
could set up a phone or in-person meeting with you.
Whether or not your complaint is resolved in this meeting, it will be forwarded to the
Governor’s Advocacy Ofﬁce for follow-up.
If your complaint is about discrimination, a DHS Civil Rights Investigator will
contact you within 20 working days to learn more about your complaint. Within 20
days of talking with the investigator, you will get a written decision on your com-
plaint. You can appeal the decision if you disagree.

Some complaints can also be ﬁled with the federal government
Complaints about discrimination or privacy of health information can also be ﬁled
with the U.S. Ofﬁce for Civil Rights. (Complaints of discrimination based on sexual
orientation are not handled by this federal ofﬁce. Those reports should come to
DHS.)
Complaints to the U.S. Ofﬁce for Civil Rights should be mailed, faxed, or emailed
within 180 days of the date when the problem occurred. This time frame applies
even if you ﬁle ﬁrst with the Department of Human Services.
They should be sent to:
Ofﬁce for Civil Rights
Dept. of Health & Human Services
2201–6th Ave. Mail Stop RX-11
Seattle, WA 98121
Fax: (206) 615-2297 E-mail: OCRComplaint@hhs.gov
For information about ﬁling these reports, you can call toll-free 1-800-368-1019,
(206) 615-2290 (voice) or (206) 615-2296 (TTY).
If a discrimination problem occurred in the Food Stamp program, you can ﬁle a re-
port with the U.S. Department of Agriculture (USDA), as well as with DHS. Send your
report within 180 days to:
U.S. Dept. of Agriculture, Ofﬁce of Civil Rights
Food & Nutrition Service, Western Region
550 Kearny Street, Room 400
San Francisco, CA 94108-2518
For information on ﬁling reports with USDA, you can call toll-free 1-800-368-1019
(voice) or (206) 615-2290 TTY.
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