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
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
Approved by:_____________________
on _________________
(Committee responsible for approving policies)
Adopted by Board of Directors on:____________________
Signature of Board Chair
or President of Organization:__________________________
HHS CACFP Nondiscrimination Policy (6/13)
Nutrition Services


00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal