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Child And Adult Care Food Program Nondiscrimination Policy Form - North Carolina Department Of Health And Human Services

North Carolina Department of Health and Human Services

Division of Public Health

Women’s & Children’s Health Section

Nutrition Services Branch

Special Nutrition Programs

CHILD AND ADULT CARE FOOD PROGRAM

Nondiscrimination Policy

Name of Institution: __________________________________ Agreement #:________

In accordance with federal law and the United States Department of Agriculture, it is the

policy of __________________________________ to prohibit discrimination against its

customers, employees, and applicants for employment on the bases 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 if 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

, 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. Department of Agriculture, Director, Office of Adjudication, 1400

Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or

email at program.intake@usda.gov.

Approved by:_____________________

on _________________

(Committee responsible for approving policies)

date)

Adopted by Board of Directors on:____________________

(date)

Signature of Board Chair

or President of Organization:__________________________

__________

(Signature)

(date)

HHS CACFP Nondiscrimination Policy (6/13)

Nutrition Services

Child And Adult Care Food Program Nondiscrimination Policy Form - North Carolina Department Of Health And Human Services