Form Hhs-699 - Discrimination Complaint - Department Of Health And Human Services - Office For Civil Rights (Ocr)

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Form Approved: OMB No. 0990-0269.
See OMB Statement on Reverse.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OFFICE FOR CIVIL RIGHTS (OCR)
DISCRIMINATION COMPLAINT
If you have questions about this form, call OCR (toll-free) at:
1-800-368-1019 (any language) or 1-800-537-7697 (TDD)
YOUR FIRST NAME
YOUR LAST NAME
Robert
Greenwald
HOME PHONE
WORK PHONE
390-2584
(
)
(
617
)
STREET ADDRESS
CITY
122 Boylston Street
Jamaica Plain
STATE
ZIP
E-MAIL ADDRESS (If available)
MA
02130
rgreenwa@law.harvard.edu
Are you filing this complaint for someone else?
Yes
No
If Yes, against whom do you believe the disrimination was directed?
FIRST NAME
LAST NAME
See Attached
See attached
I believe that I have been (or someone else has been) discriminated against on the basis of:
Race / Color / National Origin
Age
Religion
Gender (Male/Female)
See attached
Disability
Other (specify) :
Who do you think discriminated against you (or someone else)?
PERSON/AGENCY/ORGANIZATION
See Attached
STREET ADDRESS
CITY
STATE
ZIP
PHONE
(
)
When do you believe that the discrimination took place?
LIST DATE(S)
See attached
Describe briefly what happened. How and why do you believe you (or someone else) were discriminated against? Please be as
specific as possible. (Attach additional pages as needed)
See attached
Please sign and date this complaint.
SIGNATURE
DATE
09/06/2016
Filing a complaint with OCR is voluntary. However, without the information requested above, OCR may be unable to proceed with your
complaint. We collect this information under authority of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of
1973 and other civil rights statutes. We will use the information you provide to determine if we have jurisdiction and, if so, how we will
process your complaint. Information submitted on this form is treated confidentially and is protected under the provisions of the Privacy
Act of 1974. Names or other identifying information about individuals are disclosed when it is necessary for investigation of possible
discrimination, for internal systems operations, or for routine uses, which include disclosure of information outside the Department for
purposes associated with civil rights compliance and as permitted by law. It is illegal for a recipient of Federal financial assistance from
Heatlh and Human Services (HHS) to intimidate, threaten, coerce, or discriminate or retaliate against you for filing this complaint or for
taking any other action to enforce your rights under Federal civil rights laws. You are not required to use this form. You also may write a
letter or submit a complaint electronically with the same information. To submit an electronic complaint, go to our web site at:
To mail a complaint see reverse page for OCR Regional addresses.
HHS-699 (4/03) (FRONT)
EF
PSC Media Arts (301) 443-1090

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