Form AGL-07 "Older Adult Daily Living Centers Provider Self-certification and Civil Rights Compliance Form" - Pennsylvania

What Is Form AGL-07?

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

Form Details:

  • Released on September 30, 2016;
  • The latest edition provided by the Pennsylvania Department of Aging;
  • 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 printable version of Form AGL-07 by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Aging.

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Download Form AGL-07 "Older Adult Daily Living Centers Provider Self-certification and Civil Rights Compliance Form" - Pennsylvania

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1
OLDER ADULT DAILY LIVING CENTERS
PROVIDER SELF-CERTIFICATION AND CIVIL RIGHTS COMPLIANCE FORM (AGL-07)
LICENSE NUMBER:
**NAME OF LEGAL ENTITY:
**NAME OF CENTER:
**ADDRESS OF CENTER:
CENTER WEBSITE:
COUNTY:
NAME OF CENTER DIRECTOR:
EMAIL OF CENTER DIRECTOR
PHONE # OF CENTER
** Enter the name of the legal entity, center and address as stated on current license if there have been no changes.
Note: The word “discrimination” as used throughout this document shall be understood to mean
“discrimination on the basis of race, color, national origin, religious creed, ancestry, sex, age, or handicap,”
as used in Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age
Discrimination Act of 1975, and/or the Pennsylvania Human Relations Act of 1955, as amended.
Supporting documentation must be provided at initial licensure and when any change occurs in a center’s
policy, procedure, or practice regarding civil rights compliance. There is no need to provide supporting
documentation following the initial licensure unless there has been a change.
Please check either YES or NO when answering the following questions. Provide attachments as
necessary.
th
Bureau of Quality Assurance / Division of Licensing | 555 Walnut Street, 5
Fl. | Harrisburg, PA 17101 | 717.214.6716 |
www.aging.pa.gov
09/30/2016
1
OLDER ADULT DAILY LIVING CENTERS
PROVIDER SELF-CERTIFICATION AND CIVIL RIGHTS COMPLIANCE FORM (AGL-07)
LICENSE NUMBER:
**NAME OF LEGAL ENTITY:
**NAME OF CENTER:
**ADDRESS OF CENTER:
CENTER WEBSITE:
COUNTY:
NAME OF CENTER DIRECTOR:
EMAIL OF CENTER DIRECTOR
PHONE # OF CENTER
** Enter the name of the legal entity, center and address as stated on current license if there have been no changes.
Note: The word “discrimination” as used throughout this document shall be understood to mean
“discrimination on the basis of race, color, national origin, religious creed, ancestry, sex, age, or handicap,”
as used in Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age
Discrimination Act of 1975, and/or the Pennsylvania Human Relations Act of 1955, as amended.
Supporting documentation must be provided at initial licensure and when any change occurs in a center’s
policy, procedure, or practice regarding civil rights compliance. There is no need to provide supporting
documentation following the initial licensure unless there has been a change.
Please check either YES or NO when answering the following questions. Provide attachments as
necessary.
th
Bureau of Quality Assurance / Division of Licensing | 555 Walnut Street, 5
Fl. | Harrisburg, PA 17101 | 717.214.6716 |
www.aging.pa.gov
09/30/2016
2
I. CIVIL RIGHTS
A. Does the center have a policy statement that affirms a commitment to nondiscrimination in service
delivery (e.g. admissions, internal placement, facility usage, referrals, and communication with non
– verbal or non-English speaking clients) and equal opportunity and affirmative action in all
employment actions (e.g., recruitment, selection, promotion, training, apprentice programs, etc.)?
If YES____, provide a copy of the policy. If NO____, state what corrective measures will be taken
to develop a policy statement.
B. Has this center, within the calendar year, completed a Civil Rights Compliance Review for another
State or Federal Agency/Department? If YES ___, provide a copy of the other agency’s completed
review form and status of compliance. (The other agency’s form is meant to be a supporting
document; it is not meant to take the place of this self-certification and civil rights compliance form).
NO ____
C. What methods are used to orient clients, employees, and board members (if applicable) to civil
rights compliance requirements?
D. Does the center have policies and procedures for use by clients and employees in exercising their
rights to lodge civil rights complaints? If YES ____, provide a copy of the supporting document(s)
and explain how it is disseminated. If NO ____, state what corrective measures will be taken to
develop policies and procedures.
E. Has the center had a complaint of discrimination filed against it within the past 12 months by an
employee or client? If YES___, list the date of the complaint, the sex and race/national origin of
complainant, major allegations made in the complaint, the agency with which the complaint was
registered and the finding of either cause or no cause by the investigating agency. NO____
th
Bureau of Quality Assurance / Division of Licensing | 555 Walnut Street, 5
Fl. | Harrisburg, PA 17101 | 717.214.6716 |
www.aging.pa.gov
09/30/2016
3
F. Does the center have a policy and procedure that allows employees and those applicants selected
for employment to voluntarily disclose a handicap? YES ____
NO ____
1. Does the policy state reasonable accommodations will be provided to handicapped
employees?
YES ____. If NO ____, state the reason(s) why accommodations are not
being provided.
2. List examples (if any) of reasonable accommodations requested by and provided to any
handicapped employees within the past 12 months.
G. Does the center ensure programs are accessible and available to clients with hearing and visual
impairments (i.e., interpreter services, tapes, Braille)? YES ____. If NO ____, state what corrective
measures will be taken to assure access.
H. What methods were/are used to make program services accessible to the physically and/or
sensory impaired? Select all that apply.
____ Building constructed to meet ADA guidelines
____ Building modification
____ Auxiliary aids
____ Visual fire alarm devices
____ Program relocation to another structure
____ Program relocation within structure
____ Other (specify)
th
Bureau of Quality Assurance / Division of Licensing | 555 Walnut Street, 5
Fl. | Harrisburg, PA 17101 | 717.214.6716 |
www.aging.pa.gov
09/30/2016
4
II. SELF-CERTIFICATION
This is to certify that the above named facility will comply with the applicable requirements of the following
major laws and codes in all human service programs it operates.
 Title VI and Title VII of the Civil rights Act of 1964
 Section 504, Rehabilitation Act of 1973
 Age Discrimination Act of 1975
 Pennsylvania Human Relations Act of 1955, as amended
 16 PA Code, Chapter 49 (Contract Compliance Regulations)
The above named facility will not permit discrimination on the basis of race, color, religious creed,
handicap, ancestry, national origin, age, sex, or sexual orientation in any aspect of service delivery to
eligible beneficiaries, and will apply the principles of equal opportunity in all matters of employment and
contractual agreements.
________________________________________________________________________
Signature of Center Director
Date
th
Bureau of Quality Assurance / Division of Licensing | 555 Walnut Street, 5
Fl. | Harrisburg, PA 17101 | 717.214.6716 |
www.aging.pa.gov
09/30/2016
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