Form MO580-2068 "Complaint of Discrimination (By Customers, Applicants and/or the Public)" - Missouri

Form MO580-2068 or the "Complaint Of Discrimination (by Customers, Applicants And/or The Public)" is a form issued by the Missouri Department of Health and Senior Services.

The form was last revised in June 1, 2014 and is available for digital filing. Download an up-to-date Form MO580-2068 in PDF-format down below or look it up on the Missouri Department of Health and Senior Services Forms website.

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Download Form MO580-2068 "Complaint of Discrimination (By Customers, Applicants and/or the Public)" - Missouri

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Administrative Policy 3.2 A
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
COMPLAINT OF DISCRIMINATION
(By Customers, Applicants and/or the Public)
The Missouri Department of Health and Senior Services (DHSS) provides services on a non-discriminatory basis. Law prohibits difference in
treatment in the provision of services because of race, color, religion, national origin, sex, age or disability. If you believe that you have been
discriminated against in one or more of these areas you may file a complaint with DHSS or the U.S. Department of Health and Human Services
by completing this form and returning it to one of the following agencies:
Missouri Department of Health and Senior Services
U. S. Department of Health and Human Services
Office of Human Resources
Office of Civil Rights
Human Relations Officer
601 E 12th Street, Room 248
P. O. Box 570
Kansas City, MO 64106
Jefferson City, MO 65102-0570
816/426-7277
TTD: 816/426-3724
WIC Supplemental Nutrition Program: The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and
applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where
applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from
any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the
Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program
complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at
http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a
letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Dept of
Agriculture, Director, Office of Adjudication, 1400 Independence Ave., S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442, or email at
program.intake@usda.gov. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay
Service at (800) 877-8339 or (800) 845-6136 (Spanish). USDA is an equal employment provider and employer.
If you wish to file a complaint, please answer the following questions with as much detail as possible:
1. NAME (MR./MRS./MS.)
HOME or MESSAGE TELEPHONE NUMBER
ADDRESS (STREET, CITY, STATE, ZIP CODE)
WORK TELEPHONE NUMBER
2. DESCRIBE WHAT OCCURRED TO MAKE YOU BELIEVE THAT YOU WERE TREATED DIFFERENTLY THAN OTHER CLIENTS AND THE DATE THE INCIDENT(S) OCCURRED:
(Attach additional sheets of paper if needed)
3. DO YOU BELIEVE THAT THE DIFFERENCE IN TREATMENT WAS BASED ON YOUR:
RACE
COLOR
DISABILITY
SEX
NAT. ORIGIN
AGE
RELIGION
OTHER - Specify:
MO 580-2068 (6-14)
CONTINUED ON NEXT PAGE
PF-41
Administrative Policy 3.2 A
MISSOURI DEPARTMENT OF HEALTH AND SENIOR SERVICES
COMPLAINT OF DISCRIMINATION
(By Customers, Applicants and/or the Public)
The Missouri Department of Health and Senior Services (DHSS) provides services on a non-discriminatory basis. Law prohibits difference in
treatment in the provision of services because of race, color, religion, national origin, sex, age or disability. If you believe that you have been
discriminated against in one or more of these areas you may file a complaint with DHSS or the U.S. Department of Health and Human Services
by completing this form and returning it to one of the following agencies:
Missouri Department of Health and Senior Services
U. S. Department of Health and Human Services
Office of Human Resources
Office of Civil Rights
Human Relations Officer
601 E 12th Street, Room 248
P. O. Box 570
Kansas City, MO 64106
Jefferson City, MO 65102-0570
816/426-7277
TTD: 816/426-3724
WIC Supplemental Nutrition Program: The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and
applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where
applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from
any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the
Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program
complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at
http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a
letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Dept of
Agriculture, Director, Office of Adjudication, 1400 Independence Ave., S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442, or email at
program.intake@usda.gov. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay
Service at (800) 877-8339 or (800) 845-6136 (Spanish). USDA is an equal employment provider and employer.
If you wish to file a complaint, please answer the following questions with as much detail as possible:
1. NAME (MR./MRS./MS.)
HOME or MESSAGE TELEPHONE NUMBER
ADDRESS (STREET, CITY, STATE, ZIP CODE)
WORK TELEPHONE NUMBER
2. DESCRIBE WHAT OCCURRED TO MAKE YOU BELIEVE THAT YOU WERE TREATED DIFFERENTLY THAN OTHER CLIENTS AND THE DATE THE INCIDENT(S) OCCURRED:
(Attach additional sheets of paper if needed)
3. DO YOU BELIEVE THAT THE DIFFERENCE IN TREATMENT WAS BASED ON YOUR:
RACE
COLOR
DISABILITY
SEX
NAT. ORIGIN
AGE
RELIGION
OTHER - Specify:
MO 580-2068 (6-14)
CONTINUED ON NEXT PAGE
PF-41
Why do you believe that your membership in one or more of these categories was the reason for the difference in treatment? (If ‘other’ is
checked, please explain in detail what you believe to be the basis for the difference in treatment.)
4. Provide the name of the agency and/or person(s) who are responsible in the alleged difference in treatment.
AGENCY NAME
PERSON(S) INVOLVED
5. Did you report what happened to you to anyone at that agency?
Yes
No
If yes, provide the name of the person(s) you talked with and what you reported to that person.
6. Do you know of anyone else who was treated in the same manner as you? Did anyone witness what happened to you?
Yes
No
If yes, please provide their name, address and telephone number, and what happened to them (if applicable.)
If more space is needed to fully explain what occurred, please attach additional information to this form.
FORM COMPLETED BY (SIGNATURE):
DATE
MO 580-2068 (6-14)
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER
PF-41
SERVICES PROVIDED ON A NONDISCRIMINATORY BASIS
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