Form HFS185 "Client/Applicant Discrimination Claim" - Illinois

What Is Form HFS185?

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

Form Details:

  • Released on August 1, 2010;
  • The latest edition provided by the Illinois Department of Healthcare and Family Services;
  • 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 HFS185 by clicking the link below or browse more documents and templates provided by the Illinois Department of Healthcare and Family Services.

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Download Form HFS185 "Client/Applicant Discrimination Claim" - Illinois

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Illinois Department of
Healthcare and Family Services
CLIENT/APPLICANT DISCRIMINATION CLAIM
If you believe you were harassed or treated differently from other clients or applicants because of your race, protected age group,
religion, color, sex, disability or disabling condition, national origin/ancestry or marital status, you or your representative may file a
discrimination complaint with the Illinois Department of Healthcare and Family Services.
The following information will assist us in investigating your complaint:
Date:
Case# :
Client/Applicant Name:
Phone# :
(Print)
Address:
(Street)
(City)
(Zip)
Or Location Where A Message Can Reach You:
Please answer the following questions and check whether you are :
the person filing the complaint;
filing on another person's behalf with their consent.
1)
Date of Incident:
4) Your Name:
2)
Employee's Name:
5) Your Relationship to the Client/Applicant:
3)
Office Location:
6) Identify the basis (or reason) you believe caused you to be treated differently or harassed:
Race
Age
Religion
Sex
Color
Disability
National Origin/Ancestry
Marital Status
Briefly describe how, why and when you believe you were discriminated against:
Signature:
Please send the completed form to:
The Illinois Department of Healthcare and Family Services
Equal Employment Opportunity
and Affirmative Action
401 S. Clinton Street, 5th Floor
2946 Old Rochester Road
Chicago, IL 60607
Springfield, IL 62703
(312) 793-4322(voice)
(217) 782-3328(Voice)
(312) 793-1407(TTY)
(217) 785-5127(TTY)
(See next page for complaint process)
Form approved by the Forms Management Center
Print Form
Reset Form
HFS 185 (R-8-10)
Page 1 of 2
Illinois Department of
Healthcare and Family Services
CLIENT/APPLICANT DISCRIMINATION CLAIM
If you believe you were harassed or treated differently from other clients or applicants because of your race, protected age group,
religion, color, sex, disability or disabling condition, national origin/ancestry or marital status, you or your representative may file a
discrimination complaint with the Illinois Department of Healthcare and Family Services.
The following information will assist us in investigating your complaint:
Date:
Case# :
Client/Applicant Name:
Phone# :
(Print)
Address:
(Street)
(City)
(Zip)
Or Location Where A Message Can Reach You:
Please answer the following questions and check whether you are :
the person filing the complaint;
filing on another person's behalf with their consent.
1)
Date of Incident:
4) Your Name:
2)
Employee's Name:
5) Your Relationship to the Client/Applicant:
3)
Office Location:
6) Identify the basis (or reason) you believe caused you to be treated differently or harassed:
Race
Age
Religion
Sex
Color
Disability
National Origin/Ancestry
Marital Status
Briefly describe how, why and when you believe you were discriminated against:
Signature:
Please send the completed form to:
The Illinois Department of Healthcare and Family Services
Equal Employment Opportunity
and Affirmative Action
401 S. Clinton Street, 5th Floor
2946 Old Rochester Road
Chicago, IL 60607
Springfield, IL 62703
(312) 793-4322(voice)
(217) 782-3328(Voice)
(312) 793-1407(TTY)
(217) 785-5127(TTY)
(See next page for complaint process)
Form approved by the Forms Management Center
Print Form
Reset Form
HFS 185 (R-8-10)
Page 1 of 2
Illinois Department of
Healthcare and Family Services
CLIENT/APPLICANT DISCRIMINATION CLAIM
SUMMARY OF THE COMPLAINT PROCESS
1. When a telephone interview concerning discrimination is held with a client or applicant for services or benefits, the client or
applicant is mailed a Client/Applicant Discrimination Claim form (HFS 185) to complete and return. The client or applicant
should receive the form within five workdays of the date of the telephone interview. The client or applicant is requested to
return the completed form within 10 workdays. The complaint must be filed within 180 days of the alleged discriminatory act.
2. When an interview is held in person, the client or applicant is issued the Client/Applicant Discrimination Claim form and is
requested to return the completed form within five workdays.
3. When a completed Client/Applicant Discrimination Claim form is received, the Chief Equal Employment Opportunity (EEO)
Officer will assign the complaint for an investigation. The client or applicant and his or her representative shall have a right to
submit any relevant evidence in support of their claim. The result and recommendation of findings are submitted to the Chief
EEO Officer.
4. Upon receipt of the EEO Officer's complete written report, and based on the findings, one or more of the following steps may
be taken by the Chief EEO Officer:
a. Direct the EEO Officer to notify the client or applicant whether or not the case appears to have merit.
b. Seek additional information and or counsel the concerned parties.
c. Apprise the Administrator or the Director of the current status of this complaint and make recommendations as to the
course of action the Illinois Department of Healthcare and Family Services should take.
5. Within 180 days (unless an extension is required) from the date the Client/Applicant Discrimination Claim was filed, the client
or applicant should be informed of the action that the Department intends to take. The Illinois Department of Healthcare and
Family Services may extend the investigation period if necessary. The client or applicant will be advised in writing of an
extension.
6. In the event the client or applicant is not in agreement with the findings of the EEO Office or has additional information which
may affect the outcome of the findings of the EEO Office, the client or applicant must file an appeal in writing directly to the
Chief EEO Officer within 10 days of notification of the findings. The Chief EEO Officer will submit the appeal to an Illinois
Department of Healthcare and Family Services Appeals Officer who will review the original findings and the appeal and make
a determination based upon the available information. The client or applicant will be notified of the results of the appeal. The
decision of the Illinois Department of Healthcare and Family Services Appeals Officer is final.
NOTE:
A client or applicant who files an internal client discrimination claim through the EEO Office may also file discrimination
charges with governmental regulatory agencies. These agencies include but are not limited to: the Illinois Department of
Human Rights, 100 W. Randolph, Suite 10-100, Chicago, IL 60601, (312) 814-6200, TTY (217) 785-5125, or 222 S. College,
Springfield, IL 62704, (217) 785-5100, TTY (217) 785-5125, and the United States Department of Health and Human
Services / Office of Civil Rights, 233 North Michigan Avenue, Chicago, IL 60601, Suite 240, (312) 886-2359.
HFS 185 (R-8-10)
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