Instructions for Completing Self-Evaluation Checklists

							                      Instructions for DSHS Contractors :
          Completing Surveys for CORE Tool Review Criteria 1 through 3

Please complete the attached surveys, and then have your agency’s President or
Executive Director sign and date the bottom of each survey to affirm the
information provided is true and correct to the best of his or her knowledge.
These surveys must be completed before your on-site review. The QMB review
team will obtain two copies of each survey during the on-site review, and forward
one of these copies to the HHSC Civil Rights Office for review.

1: Complete the Non-Discrimination Policies and Procedures Survey by checking
Yes or No in response to each question in the survey. Use the Explain/Comment
column to provide any explanations, examples, or comments that apply to each question
in the survey. Be sure to attach copies of any written policies and procedures that
support your responses.

2: Complete the Limited English Proficiency (LEP) Policies and Procedures Survey
by checking Yes or No in response to each question in the survey. Use the
Explain/Comment column to provide any explanations, examples, or comments that
apply to each question in the survey. Be sure to attach copies of any written policies
and procedures that support your responses.

3: Complete the ADA/Section 504 Policies and Procedures Survey by checking Yes
or No in response to each question in the survey. Use the Explain/Comment column to
provide any explanations, examples, or comments that apply to each question in the
survey. Be sure to attach copies of any written policies and procedures that support
your responses. Complete the ADA Checklist for Readily Achievable Barrier
Removal by checking Yes or No in response to each item in this checklist. This
checklist also identifies the applicable ADA Accessibility Guideline (ADAAG) Standards,
as well as possible solutions for addressing any No responses that may be identified
during the completion of this checklist. A separate ADA Checklist for Readily
Achievable Barrier Removal will need to be completed once for each of the agency’s
facilities; additional copies of the checklist may be obtained from the following web-site:
http://www.usdoj.gov/crt/ada/checkweb.htm. The address of each facility evaluated
should be recorded on the coversheet of the ADA Checklist for Readily Achievable
Barrier Removal.

Questions? If you have questions about how to complete any of the surveys, need
technical assistance in addressing any problem areas identified in completing the
surveys, or need posters or additional copies of surveys, please contact the HHSC Civil
Rights Office, at (512) 438-4313 (voice), (512) 438-2960 (TDD).