Civil Rights Discrimination Complaint Form

This form should be completed if you believe you have been discriminated against while in the process of applying for or receiving any services or benefits administered, supervised, or authorized by the Cuyahoga County Department of Health and Human Services (CCDHHS), or if you have faced discrimination while participating in any programs administered by CCDHHS. To view the CCDHHS Civil Rights Plan and learn more about the methods to file a civil rights complaint, visit: https://hhs.cuyahogacounty.us/about-hhs/civil-rights

If you have a civil rights complaint related to services provided by the Division of Children and Family Services, Cuyahoga Job and Family Services, Office of Child Support Services or the Division of Senior and Adult Services please visit https://hhs.cuyahogacounty.us/about-hhs/civil-rights

First Name

Last Name

Middle Initial

Street Address

City

Zip

Home Phone

Name the entity within the Cuyahoga County Department of Health and Human Services you believe has discriminated against you:

Office of Early Childhood

Office of Homeless Services

Office of Reentry

Family and Children First Council

Fatherhood Initiative

Please name the program or service you were receiving or applying for:

Race of the Complainant:

American Indian/Alaska Native

Native Hawaiian/Other Pacific Islander

Asian

White/Caucasian

Black/African American

Other...

Complainant’s Ethnicity:

Hispanic/Latino

Not Hispanic/Latino

Sex of the Complainant:

Male

Female

Other...

Name(s) and titles(s) of who you believe discriminated against you:

Date of alleged discrimination

Working/Training Site where you were located: (if applicable)

What has been done to resolve your concern?

Please explain why you believe the treatment or incident you experienced was because of your race, color, religion, national origin, age, sex, gender identity, sexual orientation, disability, political affiliation, or belief.

New code

Please type the code above

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