Form Hhs-700 - Civil Rights Discrimination Complaint Page 4
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In addition, I understand that as a complainant I am covered by the
Department of Health and Human Services’ (HHS) regulations which protect
any individual from being intimidated, threatened, coerced, retaliated against,
or discriminated against because he/she has made a complaint, testified,
assisted, or participated in any manner in any mediation, investigation,
hearing, proceeding, or other part of HHS’ investigation, conciliation, or
enforcement process.
After reading the above information, please check ONLY ONE of the following boxes:
CONSENT: I have read, understand, and agree to the above and give permission
to OCR to reveal my identity or identifying information about me in my case file to
persons at the entity or agency under investigation or to other relevant persons,
agencies, or entities during any part of HHS’ investigation, conciliation, or
enforcement process.
CONSENT DENIED: I have read and I understand the above and do not give
permission to OCR to reveal my identity or identifying information about me. I
understand that this denial of consent is likely to impede the investigation of my
complaint and may result in closure of the investigation.
Signature:
Date:
*Please sign and date this complaint. You do not need to sign if submitting this form by email because submission by email represents your signature.
Name (Please print):
Address:
Telephone Number:
Complaint Consent Form
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HHS-700 (10/17) (BACK)
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Parent category: Legal