What information is needed to file a complaint with the HHS Office for Civil Rights?

Answer:

You may use the Discrimination Complaint Form from the HHS Office for Civil Rights available in Microsoft Word format or PDF format. You will need to save the form to your computer or other storage device.

You may also file a written complaint.  Please include the following:

• Your name, address and telephone number.
• You must sign the complaint. (If you file a complaint on someone's behalf, include his/her name, address and telephone number and state your relationship to that person - e.g., spouse, attorney, friend, etc.)
• Name and address of the institution or agency you believed discriminated against you.
• How, why, and when you believe you were discriminated against.
• Any other relevant information.

For more information, see our Fact Sheet, "How To File A Discrimination Complaint With The Office For Civil Rights". If you need assistance in filing a complaint, please call 1-800-368-1019 to contact your regional office.

Last Updated: 5/14/2008