Client Complaint or Report of Discrimination Form by axf14849


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            Oregon Department of Human Services

       Client Complaint
 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?

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

For DHS use only:
Date complaint received:_____________ Complaint received by: ______________
Copies provided to client? c Yes          c 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 (09/2010), can use 2/05 version
        DHS Client Complaint or Report of Discrimination Form

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,
   reduced 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: or you can
   call the Governor’s Advocacy Office at 1-800-442-5238.

 • If you disagree with an action taken in a Vocational
   Rehabilitation 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.
 • 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 0170 (09/2010), can use 2/05 version
               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:
    c You did not receive good customer service from DHS.
    c Personal information about you was not kept confidential by DHS.
    c You believe you were discriminated against because of:
          c Age      c Gender      c Race, color, or national origin   c Religion
          c Political beliefs      c Disability      c Sexual orientation
          c 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 >>)
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               DHS Client Complaint or Report of Discrimination Form

    Details about your complaint (continued)

    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

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

    I give DHS permission to speak to the representative filing this complaint
    on my behalf.
    Federal law protects people who file complaints from being treated badly
    or discriminated against because of it.

                                                3       DHS 0170 (09/2010), can use 2/05 version
               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
confidential, it is sent to a line supervisor for review.
The supervisor will contact you as soon as possible but within five business days of
getting 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 0170 (09/2010), can use 2/05 version
              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
complaint. 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:
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 Supplemental Nutrition Assistance
Program (SNAP), you can file a report 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
           90 Seventh St. Suite 10-100
           San Francisco, CA 94103
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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