Form HRP-1030A FORPDF "Commodity Senior Food Program (Cfsp) Civil Rights Complaint / Grievance" - Arizona

What Is Form HRP-1030A FORPDF?

This is a legal form that was released by the Arizona Department of Economic Security - a government authority operating within Arizona. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2017;
  • The latest edition provided by the Arizona Department of Economic Security;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HRP-1030A FORPDF by clicking the link below or browse more documents and templates provided by the Arizona Department of Economic Security.

ADVERTISEMENT
ADVERTISEMENT

Download Form HRP-1030A FORPDF "Commodity Senior Food Program (Cfsp) Civil Rights Complaint / Grievance" - Arizona

Download PDF

Fill PDF online

Rate (4.6 / 5) 70 votes
Page background image
CSFP
Commodity
Senior
Food
Pro
gram
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1030A FORPDF (8-17)
Page 1 of 3
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
CIVIL RIGHTS COMPLAINT / GRIEVANCE
COMPLAINANT INFORMATION
NAME (Last, First, M.I.)
DATE
ADDRESS (No., Street)
CITY
STATE
ZIP CODE
HOME PHONE NUMBER
CELL PHONE NUMBER
EMAIL
TYPE OF DISCRIMINATION:
Race
Color
National Origin
Sex
Age
Disability
Reprisal or Retaliation
STATUS OF PERSON FILING COMPLAINT / GRIEVANCE:
Individual
Organization
Employee
Other:
STATEMENT OF COMPLAINT / GRIEVANCE
(Include type of discrimination charged and the specific incident and date(s) in which it occurred)
Routing (send one copy to):
Agency/Civil Rights Coordinator
Department of Economic Security / Coordinated Hunger Relief Program
1789 West Jefferson Street, Mail Drop 6282
Phoenix, AZ 85007
Lhamman@azdes.gov
(Keep original for your records)
You may also send a discrimination
(1) mail: U.S. Department of Agriculture
complaint directly to:
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue SW
Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442;
(3) email: program.intake@usda.gov
You may also call:
DES/Coordinated Hunger Relief Program (602) 771-2788; or
DES/ADA Liaison (602) 771-7500
AGENCY CIVIL RIGHTS OFFICE USE ONLY
09/13/2017
DATE COMPLAINT RECEIVED
COMPLAINT NUMBER
AGENCY LOCATION OF INCIDENT
NAME OF PERSON RECEIVING COMPLAINT
SIGNATURE
See page 3 for USDA nondiscrimination and EOE/ADA/LEP/GINA statements
CSFP
Commodity
Senior
Food
Pro
gram
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
HRP-1030A FORPDF (8-17)
Page 1 of 3
Division of Aging and Adult Services (DAAS)
Coordinated Hunger Relief Program
COMMODITY SENIOR FOOD PROGRAM (CSFP)
CIVIL RIGHTS COMPLAINT / GRIEVANCE
COMPLAINANT INFORMATION
NAME (Last, First, M.I.)
DATE
ADDRESS (No., Street)
CITY
STATE
ZIP CODE
HOME PHONE NUMBER
CELL PHONE NUMBER
EMAIL
TYPE OF DISCRIMINATION:
Race
Color
National Origin
Sex
Age
Disability
Reprisal or Retaliation
STATUS OF PERSON FILING COMPLAINT / GRIEVANCE:
Individual
Organization
Employee
Other:
STATEMENT OF COMPLAINT / GRIEVANCE
(Include type of discrimination charged and the specific incident and date(s) in which it occurred)
Routing (send one copy to):
Agency/Civil Rights Coordinator
Department of Economic Security / Coordinated Hunger Relief Program
1789 West Jefferson Street, Mail Drop 6282
Phoenix, AZ 85007
Lhamman@azdes.gov
(Keep original for your records)
You may also send a discrimination
(1) mail: U.S. Department of Agriculture
complaint directly to:
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue SW
Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442;
(3) email: program.intake@usda.gov
You may also call:
DES/Coordinated Hunger Relief Program (602) 771-2788; or
DES/ADA Liaison (602) 771-7500
AGENCY CIVIL RIGHTS OFFICE USE ONLY
09/13/2017
DATE COMPLAINT RECEIVED
COMPLAINT NUMBER
AGENCY LOCATION OF INCIDENT
NAME OF PERSON RECEIVING COMPLAINT
SIGNATURE
See page 3 for USDA nondiscrimination and EOE/ADA/LEP/GINA statements
HRP-1030A FORPDF (8-17)
Page 2 of 3
COMPLAINT INSTRUCTIONS
The USDA has found that many “civil rights” complaints are actually customer service issues (claims of rudeness,
impatience, lack of understanding or compassion) and, as much as possible, want these matters resolved on a local
level. Ultimately our goal is to ensure that civil rights are honored and the complainant is satisfied that their complaint
has been taken seriously, addressed and resolved. If a client reports unfair treatment that they perceive to be based
on any of the protected classes or if they simply feel that they have been discriminated against and want to make
a complaint, you must assist them.
Keep copies of the Complaint Grievance Form on file for those who wish to file a written complaint, and inform all
staff and volunteers serving clients on how to use it to record a complaint. If a client declines to complete the form
in writing you must complete it for them from their verbal complaint.
Notify your ERA about the complaint and forward a copy of the complaint form. Your ERA representative will
forward the complaint to DES/HRP. Your ERA representative will follow-up with DES/HRP for advice and
guidance in identifying corrective action to be taken, if necessary, to satisfy the complainant and to prevent further
complaints against the agency.
DES/HRP will also notify ERA of their determination of whether the complaint involves a “protected class” and
suggest the plan for resolution. If the complaint involves a protected class, it is forwarded to the USDA Food
and Nutrition Service (FNS) for processing. (Once the complaint is with the FNS a decision letter must be issued
within 90 days.)
The complaint can be sent directly to USDA by mail to USDA, Office of the Assistant Secretary for Civil Rights,
1400 Independence Avenue SW, Washington, D.C. 20250-9410; by phone to (866) 632-9992 (toll free),
(202) 260-1026 or (800) 877-8339 (TDD); by fax to: (202) 690-7442; or by email to: program.intake@usda.gov.
Often the complaint describes poor customer service or a misunderstanding due to language or other reason.
Using their good judgment, RFB and Distribution Site staff should accomplish resolution of the conflict within
thirty days.
A letter describing the final outcome of the complaint and copies of correspondence related to resolution of the
complaint will be forwarded by the RFB to DES/HRP and the Distribution Site within 60 days.
DOCUMENTATION
It is critical that you fully document each step from the initial complaint to the resolution.
Use the Complaint Grievance Form, whenever possible, and take good notes!
Document in writing each conversation and action taken. Keep a copy of all documentation and post in your
agency’s Civil Rights Complaint/Grievance Log.
VERBAL COMPLAINTS
If a verbal complaint is received and the client is not willing to place allegations in writing, the person receiving
the complaint may write up the elements of the complaint for the complainant using the Complaint/Grievance
Form. The client may directly register a complaint of discrimination with USDA by mail to USDA, Office of the
Assistant Secretary for Civil Rights, 1400 Independence Avenue SW, Washington, D.C. 20250-9410; by phone
to (866) 632-9992 (toll free), (202) 260-1026 or (800) 877-8339 (TDD); by fax to: (202) 690-7442; or by email to:
program.intake@usda.gov. The client may also call: DES/Coordinated Hunger Relief Program (602) 771-2788
or the DES/ADA Liaison (602) 771-7500.
Every effort needs to be made to obtain:
{{
Name, address, telephone number, or other means of contacting the complainant;
{{
Specific location and organization delivering service/benefit;
{{
Nature of the incident or action that led the complainant to feel discriminated against;
{{
Basis on which the complainant feels discrimination occurred (race, color, national origin, age, sex, religion,
{{
political beliefs, disability, reprisal or retaliation etc.);
Names, titles, and business address of persons who may have knowledge of the discriminatory action; and
{{
Date(s) during which the alleged discriminatory actions occurred, or if continuing, the duration of such actions.
{{
Anonymous complaints are to be handled just as any other complaint, though of course, full resolution will not be
possible.
HRP-1030A FORPDF (8-17)
Page 3 of 3
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies,
the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are
prohibited from discriminating based on race, color, national origin, sex, disability, age or reprisal or retaliation for prior civil
rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print,
audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits.
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service
at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027)
found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed
to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call
(866) 632-9992. Submit your completed form or letter to USDA by:
(1)
mail:
U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2)
fax:
(202) 690-7442; or
(3)
email: program.intake@usda.gov.
This institution is an equal opportunity provider.
Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the
Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of
1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination
in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age,
disability, genetics and retaliation. To request this document in alternative format or for further information about this policy,
contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for DES services is available upon request.
• Disponible en español en línea o en la oficina local.
Page of 3