DSHS Form 22-552 "Discrimination Complaint - Nondiscrimination in the Basic Food Program" - Washington

What Is DSHS Form 22-552?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2022;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Available in Arabic;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSHS Form 22-552 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 22-552 "Discrimination Complaint - Nondiscrimination in the Basic Food Program" - Washington

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DISCRIMINATION COMPLAINT
CONTACT: INVESTIGATIONS UNIT ADMINISTRATOR
VOICE: (360) 725-5821 or 1-800-521-8060
GRIEVANCE COORDINATOR FOR SECTION 504,
TTY: (360) 586-4289 or 1-800-521-8061
TITLE II AND OTHER CIVIL RIGHTS LAWS
FAX: (360) 586-0500
Nondiscrimination
DEPARTMENT OF SOCIAL AND HEALTH SERVICES
EMAIL: iraucomplaints@dshs.wa.gov
HUMAN RESOURCES DIVISION
INVESTIGATIONS UNIT
PO BOX 45830
in the Basic Food
OLYMPIA, WA 98504-5830
NAME OF PERSON FILING COMPLAINT
TELEPHONE NUMBERS 1. WORK 2. HOME
Program
1.
2.
HOME ADDRESS
STREET
CITY
STATE
ZIP CODE
NAME AND POSITION OF PERSON WHO DISCRIMINATED AGAINST YOU
TELEPHONE NUMBER
DSHS OFFICE
CITY
STATE
ZIP CODE
CLIENT IDENTIFICATION NO.
This brochure contains:
Basis:
Color
Sex
Creed
Reprisal or Retaliation
n
U.S. Department of Agriculture Food
Race
Disability
National Origin
Political Beliefs
and Nutrition Service Civil Rights
Age
Religion
Use of Dog Guide or Service Animal
Sexual Orientation
Policy for the Basic Food Program.
Recently Separated Veteran or Other Protected Status
n
Services available to persons who
believe they were discriminated
Please describe what happened and when (use extra page(s) if necessary):
against in the Basic Food Program.
Human Resources Division
Investigations Unit (IU)
“Commitment to Equality for All”
YOUR SIGNATURE
DATE
DSHS 22-552(X) (Rev. 6/22)
DISCRIMINATION COMPLAINT
CONTACT: INVESTIGATIONS UNIT ADMINISTRATOR
VOICE: (360) 725-5821 or 1-800-521-8060
GRIEVANCE COORDINATOR FOR SECTION 504,
TTY: (360) 586-4289 or 1-800-521-8061
TITLE II AND OTHER CIVIL RIGHTS LAWS
FAX: (360) 586-0500
Nondiscrimination
DEPARTMENT OF SOCIAL AND HEALTH SERVICES
EMAIL: iraucomplaints@dshs.wa.gov
HUMAN RESOURCES DIVISION
INVESTIGATIONS UNIT
PO BOX 45830
in the Basic Food
OLYMPIA, WA 98504-5830
NAME OF PERSON FILING COMPLAINT
TELEPHONE NUMBERS 1. WORK 2. HOME
Program
1.
2.
HOME ADDRESS
STREET
CITY
STATE
ZIP CODE
NAME AND POSITION OF PERSON WHO DISCRIMINATED AGAINST YOU
TELEPHONE NUMBER
DSHS OFFICE
CITY
STATE
ZIP CODE
CLIENT IDENTIFICATION NO.
This brochure contains:
Basis:
Color
Sex
Creed
Reprisal or Retaliation
n
U.S. Department of Agriculture Food
Race
Disability
National Origin
Political Beliefs
and Nutrition Service Civil Rights
Age
Religion
Use of Dog Guide or Service Animal
Sexual Orientation
Policy for the Basic Food Program.
Recently Separated Veteran or Other Protected Status
n
Services available to persons who
believe they were discriminated
Please describe what happened and when (use extra page(s) if necessary):
against in the Basic Food Program.
Human Resources Division
Investigations Unit (IU)
“Commitment to Equality for All”
YOUR SIGNATURE
DATE
DSHS 22-552(X) (Rev. 6/22)
USDA – FOOD AND NUTRITION SERVICE
Basic Food Discrimination Complaints
CIVIL RIGHTS POLICY FOR THE BASIC
FOOD* PROGRAM
If you believe the Department of Social
We need specific information to show
and Health Services has discriminated
that, despite meeting eligibility
In accordance with Federal civil rights
against you, or if you know of
requirements, you were denied benefits
law and U.S. Department of Agriculture
discrimination in the Basic Food Program,
or treated poorly based on the reasons
civil rights regulations and policies,
on the basis of race, color, national
listed above. Information will be kept as
the USDA, it’s Agencies, officies, and
origin, age, sex (including gender identity
confidential as possible.
employees, and institutions participating
in or administering USDA programs are
and sexual orientation), disability, use of
The Human Resources Division,
You may also file your complaint
prohibited from discriminating based on
dog guide or service animal, political
Investigations Unit staff will review your
race, color, national origin, sex (including
directly with:
beliefs, religion, creed, recently
complaint to determine if we are
gender identity and sexual orientation),
separated veteran status or other
USDA
authorized to investigate your allegations.
religious creed, disability, age, political
protected veteran status, or reprisal or
Office of the Assistant Secretary
beliefs, or reprisal or retaliation for prior
If so, an IU staff will be assigned to
for Civil Rights
retaliation for prior civil rights activity,
civil rights activity in any program or
begin an investigation. If the allegations
1400 Independence Avenue, S.W.
please report that discrimination to the
activity conducted or funded by USDA.
are substantiated, we will recommend
Washington, D.C. 20250-9410
Human Resources Division, Investigations
appropriate action be taken.
1-866-632-9992 (voice)
Unit, Department of Social and Health
To file a complaint of discrimination,
1-800-877-8339 (TTY)
Services within 180 days of the
Retaliation Prohibited
write to:
discriminatory act. This report can be
The Department of Social and Health
USDA
made by completing the form on the
Services will not tolerate retaliation against
Office of the Assistant Secretary
reverse side or by calling our office.
an individual because they filed a complaint
for Civil Rights
1400 Independence Avenue, S.W.
or assisted in the investigation of a
Washington, D.C. 20250-9410
complaint.
1-866-632-9992 (voice)
Investigations Unit
1-800-877-8339 (TTY)
Contact Numbers
(360) 725-5821
USDA is an equal opportunity provider and
1-800-521-8060
employer.
TTY (360) 586-4289
* At the federal level, the Basic Food Program is
TTY 1-800-521-8061
known as the Supplemental Nutrition Assistance
Program.
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