Form Hhs-699 - Discrimination Complaint - Department Of Health And Human Services - Office For Civil Rights (Ocr) Page 2

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Complete Form Hhs-699 - Discrimination Complaint - Department Of Health And Human Services - Office For Civil Rights (Ocr) with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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(The remaining information on this form is optional. Failure to answer these voluntary

questions will not affect OCR’s decision to process your complaint.)

Do you need special accommodations for us to communicate with you about this complaint (check all that apply)?

Braille

Large Print

Cassette tape

Computer diskette

Electronic mail

TDD

Sign language interpreter (specify language):

Foreign language interpreter (specify language):

Other:

If we cannot reach you directly, is there someone we can contact to help us reach you?

FIRST NAME

LAST NAME

Costello

Kevin

HOME PHONE

WORK PHONE

333-3333

390-2578

(

)

(

617

)

STREET ADDRESS

CITY

122 Boylston Street

Jamaica Plain

STATE

ZIP

E-MAIL ADDRESS (If available)

02130

kcostello@law.harvard.edu

Have you filed your complaint anywhere else? If so, please provide the following. (Attach additional pages as needed.)

PERSON / AGENCY / ORGANIZATION / COURT NAME(S)

DATE(S) FILED

CASE NUMBER(S) (If known)

To help us better serve the public, please provide the following information for the person you believe was discriminated

against (you or the person on whose behalf you are filing).

ETHNICITY (select one)

RACE (select one or more)

Hispanic or Latino

American Indian or Alaska Native

Asian

Native Hawaiian or Other Pacific Islander

Not Hispanic or Latino

Black or African American

White

Other (specify) :

PRIMARY LANGUAGE SPOKEN (if other then English)

HOW DID YOU LEARN ABOUT THE OFFICE FOR CIVIL RIGHTS?

To mail a complaint, please type or print, and return completed complaint to the

OCR Regional Address based on the region where the alleged discrimination took place.

Region I - CT, ME, MA, NH, RI, VT

Region IX - AZ, CA, HI, NV, AS, GU,

Region V - IL, IN, MI, MN, OH, WI

The U.S. Affiliated Pacific Island Jurisdictions

Office for Civil Rights

Department of Health & Human Services

JFK Federal Building - Room 1875

233 N. Michigan Ave. - Suite 240

90 7th Street, Suite 4-100

Boston, MA 02203

Chicago, IL 60601

San Francisco, CA 94103

(617) 565-1340; (617) 565-1343 (TDD)

(312) 886-2359; (312) 353-5693 (TDD)

(415) 437-8310; (415) 437-8311 (TDD)

(617) 565-3809 FAX

(312) 886-1807 FAX

(415) 437-8329 FAX

Region II - NJ, NY, PR, VI

Region VI - AR, LA, NM, OK, TX

Office for Civil Rights

Department of Health & Human Services

26 Federal Plaza - Suite 3313

1301 Young Street - Suite 1169

Region X - AK, ID, OR, WA

New York, NY 10278

Dallas, TX 75202

(212) 264-3313; (212) 264-2355 (TDD)

(214) 767-4056; (214) 767-8940 (TDD)

Office for Civil Rights

(212) 264-3039 FAX

(214) 767-0432 FAX

Department of Health & Human Services

2201 Sixth Avenue - Mail Stop RX-11

Region VII - IA, KS, MO, NE

Region III - DE, DC, MD, PA, VA, WV

Seattle, WA 98121

Office for Civil Rights

(206) 615-2290; (206) 615-2296 (TDD)

Department of Health & Human Services

(206) 615-2297 FAX

601 East 12th Street - Room 248

150 S. Independence Mall West - Suite 372

Kansas City, MO 64106

Philadelphia, PA 19106-3499

(816) 426-7277; (816) 426-7065 (TDD)

(215) 861-4441; (215) 861-4440 (TDD)

(816) 426-3686 FAX

(215) 861-4431 FAX

Region VIII - CO, MT, ND, SD, UT, WY

Region IV - AL, FL, GA, KY, MS, NC, SC, TN

Office for Civil Rights

Department of Health & Human Services

1961 Stout Street - Room 1426

61 Forsyth Street, SW. - Suite 3B70

Denver, CO 80294

Atlanta, GA 30323

(303) 844-2024; (303) 844-3439 (TDD)

(404) 562-7886; (404) 331-2867 (TDD)

(303) 844-2025 FAX

(404) 562-7881 FAX

Burden Statement

Public reporting burden for the collection of information on this complaint form is estimated to average 45 minutes per response, including the time for

reviewing instructions, gathering the data needed and entering and reviewing the information on the completed complaint form. An agency may not

conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid control number. Send comments

regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: HHS/OS Reports

Clearance Officer, Office of Information Resources Management, 200 Independence Ave. S.W., Room 531H, Washington, D.C. 20201.

HHS-699 (4/03) (BACK)