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                              Sample Notice Informing Individuals About Nondiscrimination and


    

    

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Sample Notice Informing Individuals About Nondiscrimination and Accessibility Requirements








  
  
    

  
      





**Sample Notice Informing Individuals About Nondiscrimination and Accessibility Requirements**

[**Name of covered entity**] complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, and gender identity). [**Name of covered entity**] does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, and gender identity).

[Name of covered entity]:

Provides free aids and services to people with disabilities to communicate effectively with us, such as:
	Qualified sign language interpreters
		Written information in other formats (large print, audio, accessible electronic formats, other formats)
	Provides free language services to people whose primary language is not English, such as:
	Qualified interpreters
		Information written in other languages
	If you need these services, contact [Name of Civil Rights Coordinator]If you believe that [**Name of covered entity**] has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, and gender identity), you can file a grievance with:

[**Name and Title of Civil Rights Coordinator**],
	[**Mailing Address**],
	[**Telephone number**],
	[**TTY number**—if covered entity has one],
	[**Fax**],
	[**Email**].You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, [**Name and Title of Civil Rights Coordinator**] is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at https://www.hhs.gov/ocr/complaints/index.html.

                    
  


Content created by Office for Civil Rights (OCR) Content last reviewed April 16, 2024Back to top
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