Pa Civil Rights Compliance Form PDF Details

Ensuring civil rights compliance is a pivotal aspect for many organizations and facilities within Pennsylvania, necessitating a thorough understanding of the Pa Civil Rights Compliance form. This form is a comprehensive questionnaire designed to affirm an entity's adherence to non-discrimination policies in both service provision and employment practices. It requires the submission of detailed information including the facility's legal name, addresses, contact information of responsible officials, as well as the facility's type, ranging from multi-facility systems to single-site operations. The heart of the compliance form lies within its probing inquiries into how organizations develop, disseminate, and enforce non-discrimination policies. This encompasses methods of reaching out to non-English speakers, ensuring accessibility for individuals with disabilities, and outlining procedures for raising and addressing complaints of discrimination. By delving into such depths, the form serves as both a tool for self-audit by organizations and a mechanism for state oversight, ensuring that services and employment opportunities within the state of Pennsylvania are offered with equity, dignity, and respect for all individuals, regardless of race, color, religious creed, disability, ancestry, national origin, age, or sex.

QuestionAnswer
Form NamePa Civil Rights Compliance Form
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other namescompliance civil rights pa, civil right compliance, pa civil rights compliance, pennsylvania civil rights survey

Form Preview Example

CIVIL RIGHTS COMPLIANCE QUESTIONNAIRE

Certificate/Licensing Number:

NEW:_____

RENEWAL:______

 

 

 

 

Legal Entity Name

 

 

 

 

 

Responsible Official

Mr. ( ) Ms. ( )

Mrs. ( )

 

 

Title

 

Address

 

 

 

 

 

 

 

City

County

State

Zip Code

 

 

 

 

Phone #: (

)

 

 

 

 

 

Facility Name

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

City

County

State

Zip Code

 

 

Facility Administrator/Director

 

 

 

 

 

Phone #: (

)

email address:

 

 

 

 

 

NOTE:

Type of System:

_____Multi-facility (One owner, many sites)

_____Multi-type (One owner, many services)

_____Single site (One owner, one site)

_____Other (specify)

PROGRAM:

TYPE OF

 

Service

 

 

Personal Care Home

 

 

 

Child Day Care

 

 

 

Child Welfare Service

 

(Public)

 

Child Welfare Service

 

(Private)

 

Office of MHSAS

 

 

 

Office of Mental

 

Retardation

 

 

 

If additional space is required, please attach a separate 81/2 x 11 sheet to complete answers. Please denote license number on additional sheets. Be sure to number your corresponding answer.

Nondiscrimination in Employment and Services

1)Has the facility developed a nondiscrimination in service policy statement and a nondiscrimination in employment policy statement, signed by the responsible official, that advises clients/residents/parents/guardians, the public and employees that services and employment are provided in a nondiscriminatory manner, without regard to race, sex, color, national origin (address issue of Limited English Proficiency, in the service policy only), ancestry, religious creed, disability, and age?

___Yes

Provide copy (ies).

___No

2)How are the policies disseminated to clients/residents/parents/guardians, the general public and employees of the facility? Check all that apply.

___Employee/Client Orientation

___Staff Meetings/Conferences

___Language Card

___Written Announcements

___Interpreter Services

___Other (explain)

___Postings (specify locations)

___Sign Language

 

3) Does the facility currently serve Non-English speaking clients?

___Yes (if yes, explain method used to communicate with them)

___No

4)If the facility advertises its services and employment opportunities to the public, does the facility include the nondiscrimination clause in brochures, media notices and/or posters?

___Yes (provide sample of AD)

___No (Explain)

1

5)Are clients, residents, parents/guardians informed that complaints of discrimination may be filed with the U.S. Department of Health and Human Services’ Office of Civil Rights, the DPW Bureau of Equal Opportunity

(BEO) and/or the Pennsylvania Human Relations Commission (PHRC)?

___Yes (Explain how the content is disseminated)

___ No (Please Explain)

6)Has information been provided to all staff regarding their rights to file complaints of employment discrimination based on Title VII of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and/or the Pennsylvania Human Relations Act of 1955, as amended with the PHRC or Equal Employment Opportunity Commission (EEOC)?

___ Yes (Please specify method used to inform staff)

____ No

___Employee orientation

___Staff meetings/conferences

___Written announcements

___Other (explain)

7)Are restrooms, drinking fountains (e.g. human needs facilities) accessible to disabled clients/ residents/ parents/ employees/ visitors?

___ Yes

____ No ( Explain).

8)How are minorities and persons with disabilities or with Limited English Proficiency integrated into programs and activities?

Please Explain

9)What methods are employed to make services accessible to those who may have mobility or sensory

impairments? CHECK ALL THAT APPLY

___Building modifications

___Program relocation within the structure

___Other (specify)

___Auxiliary aids

___Program relocation to another structure

 

10)Does the facility’s nondiscrimination policy state that a reasonable accommodation will be provided for employees/clients with a disability (e.g. hearing, speech, vision, mobility impairments)? Have any been

granted/denied in the past 12 months?

Please Explain.

11)Within the last 12 months, have any complaints of discrimination been filed with PHRC or EEOC? List each and explain in detail the current status.

Governing Board – If Applicable

1)What policy or criteria is used to select Board members?

2)If the facility has a Board, describe methods and materials used to orient the Board to its Civil Rights compliance requirements.

The information submitted is, to the best of my knowledge, true and we intend to be bound by it.

___________________________

_______________________________

____________

Responsible Official Name (Print)

Signature

Date

NOTE: An unannounced facility on-site review may be conducted by BEO. (Rev 10-08)

2

Attachment I

License Number__________

Facility___________________________

Language of Current Limited English Proficient Clients

Current Clients Served

Total

Black

 

Hispanic

 

White

 

Native

Asian/Pacific

OTHERS

 

 

 

 

 

 

 

 

 

American

Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

F

M

 

F

M

 

F

M

F

M

 

F

M

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total

Total Client Admissions in the Past 12 Months

Black

 

Hispanic

 

White

 

Native

Asian/Pacific

OTHERS

 

 

 

 

 

 

 

 

 

American

Islander

 

 

 

M

 

F

M

 

F

M

 

F

M

 

F

M

 

F

 

 

 

 

 

 

 

M

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spanish

Chinese (Specify Dialects)

Russian

Cambodian

Vietnamese

Other

 

(Specify Language)

 

 

Board Composition – Should be reflective of community and client base –If NO Board mark N/A

Board Member

Race

Sex

Disability

Group Represented

Date Term

(Names may be omitted)

*

 

 

 

Expires

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Race Code: B = Black, H = Hispanic, W = White, NA = Native American, A/PI = Asian/Pacific Islander

Employment Information – Current Employees

Job Title/

Total Staff

Black

 

Hispanic

White

Classification

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

M

 

F

M

F

M

F

 

 

 

 

 

 

 

 

 

 

Native

American

MF

Asian/

 

 

Pacific

Others

Islander

 

 

M

F

M

F

 

 

 

 

3

For recruitment purposes: Minority/Women/Disabled Groups Contacted

Current Client Information: Please fill in the number of clients served below.

Name of Organization

Contacted

Group Represented

(Minority/Women/Disabled)

Purpose of

Contact

Method of

Contact

Phone/Mail

Date of Contact

Name of Person

Contacted

Workforce should show parity in keeping with community/client base served.

Current Employees Enrolled in Training Programs – listing of any courses offered over the past 12 months

 

 

 

 

 

 

 

 

 

Native

Asian/

 

 

Course Title

Total

Black

Hispanic

White

American

Pacific

Others

 

 

 

 

 

 

 

 

 

 

 

Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

F

M

F

M

F

M

F

M

F

M

F

M

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Completed by MH/MR ONLY

 

 

 

 

 

 

 

 

 

 

 

Native

 

Asian/

 

 

 

Total

Black

Hispanic

 

White

American

 

Pacific

Others

 

 

 

 

 

 

 

 

 

 

 

 

 

Islander

 

 

Service Offered under

M

F

M

F

M

F

M

 

F

M

 

F

M

 

F

M

F

license number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REV (10/08)

4

COMMONWEALTH OF PENNSYLVANIA (►Use Private Letterhead)

SAMPLE # 1 - CENTRAL REGION

SUBJECT: Nondiscrimination Policy Statement

Equal Employment Opportunity

TO: Staff

FROM: (►Insert Director’s Name and Signature)

An open and equitable personnel systems will be established and maintained. Personnel policies, procedures and practices will be designed to prohibit discrimination on the basis of race, color, religious creed, disability, ancestry, national origin (including limited English proficiency), age, or sex.

Employment opportunities shall be provided for applicants with disabilities and reasonable accommodation(s) shall be made to meet the physical or mental limitations of qualified applicants or employees.

Any employee who believes they have been discriminated against, may file a complaint of discrimination with any of the following.

(►Insert Provider/Facility’s Name)

(►Insert Address)

Department of Public Welfare

PA Human Relations Commission

Bureau of Equal Opportunity

Harrisburg Regional Office

Room 223, Health & Welfare Building

Riverfront Office Center

625 Forster Street

1101 S. Front St., 5th Floor

Harrisburg, PA 17120

Harrisburg, PA 17104

U.S. Dpt. of Health & Human Services

Office for Civil Rights

Suite 372, Public Ledger Bldg.

150 South Independence Mall West

Philadelphia, PA 19106-9111

5

COMMONWEALTH OF PENNSYLVANIA (►Use Private Letterhead)

SAMPLE # 2 – CENTRAL REGION

SUBJECT: Nondiscrimination in Services

TO: Patients/Clients/Residents/Parents

(►Insert one of the above, as applicable)

FROM: (►Insert Director’s Name and Signature)

Admissions, the provisions of services, and referrals of clients shall be made without regard to race, color, religious creed, disability, ancestry, national origin (including limited English proficiency), age, or sex.

Program services shall be made accessible to eligible persons with disabilities through the most practical and economically feasible methods available. These methods include, but are not limited to, equipment redesign, the provision of aides, and the use of alternative service delivery locations. Structural modifications shall be considered only as a last resort among available methods.

Any individual/client/patient/student (and /or their guardian) who believes they have been discriminated against, may file a complaint of discrimination with:

(►Insert Provider/Facility Name)

(►Insert Address)

Department of Public Welfare

PA Human Relations Commission

Bureau of Equal Opportunity

Harrisburg Regional Office

Room 223, Health & Welfare Building

Riverfront Office Center

625 Forster Street

1101 S. Front St., 5th Floor

Harrisburg, PA 17120

Harrisburg, PA 17104

U.S. Dpt. of Health & Human Services

Office for Civil Rights

Suite 372, Public Ledger Bldg.

150 South Independence Mall West

Philadelphia, PA 19106-9111

6

COMMONWEALTH OF PENNSYLVANIA (►Use Private Letterhead)

SAMPLE # 1 – SOUTHEAST REIGON

SUBJECT: Nondiscrimination Policy Statement

Equal Employment Opportunity

TO: Staff

FROM: (►Insert Director’s Name and Signature)

An open and equitable personnel systems will be established and maintained. Personnel policies, procedures and practices will be designed to prohibit discrimination on the basis of race, color, religious creed, disability, ancestry, national origin (including limited English proficiency), age, or sex.

Employment opportunities shall be provided for applicants with disabilities and reasonable accommodation(s) shall be made to meet the physical or mental limitations of qualified applicants or employees.

Any employee who believes they have been discriminated against, may file a complaint of discrimination with any of the following.

(►Insert Provider/Facility’s Name)

(►Insert Address)

Department of Public Welfare

PA Human Relations Commission

Bureau of Equal Opportunity

110 North 8th Street

Room 223, Health & Welfare Building

Suite 501

625 Forster Street

Philadelphia, PA 19107

Harrisburg, PA 17120

 

U.S. Dpt. of Health & Human Services

Commonwealth of Pennsylvania

Office for Civil Rights

DPW/ Bureau of Equal Opportunity

Suite 372, Public Ledger Bldg.

Southeast Regional Office

150 South Independence Mall West

801 Market Street, Suite 5034

Philadelphia, PA 19106-9111

Philadelphia, PA 19107

7

COMMONWEALTH OF PENNSYLVANIA (►Use Private Letterhead)

SAMPLE # 2 – SOUTHEAST REGION

SUBJECT: Nondiscrimination in Services

TO: Patients/Clients/Residents/Parents

(►Insert one of the above, as applicable)

FROM: (►Insert Director’s Name and Signature)

Admissions, the provisions of services, and referrals of clients shall be made without regard to race, color, religious creed, disability, ancestry, national origin (including limited English proficiency), age, or sex.

Program services shall be made accessible to eligible persons with disabilities through the most practical and economically feasible methods available. These methods include, but are not limited to, equipment redesign, the provision of aides, and the use of alternative service delivery locations. Structural modifications shall be considered only as a last resort among available methods.

Any individual/client/patient/student (and /or their guardian) who believes they have been discriminated against, may file a complaint of discrimination with:

(►Insert Provider/Facility Name)

(►Insert Address)

Department of Public Welfare

PA Human Relations Commission

Bureau of Equal Opportunity

110 North 8th Street

Room 223, Health & Welfare Building

Suite 501

625 Forster Street

Philadelphia, PA 19107

Harrisburg, PA 17120

 

U.S. Dpt. of Health & Human Services

Commonwealth of Pennsylvania

Office for Civil Rights

DPW/ Bureau of Equal Opportunity

Suite 372, Public Ledger Bldg.

Southeast Regional Office

150 South Independence Mall West

801 Market Street, Suite 5034

Philadelphia, PA 19106-9111

Philadelphia, PA 19107

8

COMMONWEALTH OF PENNSYLVANIA (►Use Private Letterhead)

SAMPLE # 1 – WESTERN REGION

SUBJECT: Nondiscrimination Policy Statement

Equal Employment Opportunity

TO: Staff

FROM: (►Insert Director’s Name and Signature)

An open and equitable personnel systems will be established and maintained. Personnel policies, procedures and practices will be designed to prohibit discrimination on the basis of race, color, religious creed, disability, ancestry, national origin, age, or sex.

Employment opportunities shall be provided for applicants with disabilities and reasonable accommodation(s) shall be made to meet the physical or mental limitations of qualified applicants or employees.

Any employee who believes they have been discriminated against, may file a complaint of discrimination with any of the following.

(►Insert Provider/Facility’s Name)

(►Insert Address)

Department of Public Welfare

PA Human Relations Commission

Bureau of Equal Opportunity

301 Fifth Avenue

Room 223, Health & Welfare Building

Suite 390, Piatt Place

625 Forster Street

Pittsburgh, PA 15222

Harrisburg, PA 17120

 

U. S. Department of Health and Human Services

Department of Public Welfare

Office for Civil Rights

Bureau of Equal Opportunity

Suite 372, Public Ledger Bldg.

Western Regional Office

150 South Independence Mall West

301 Fifth Avenue

Philadelphia, PA 19106

Suite 410, Piatt Place

 

Pittsburgh, PA 15222-1210

9

COMMONWEALTH OF PENNSYLVANIA (►Use Private Letterhead)

SAMPLE # 2 – WESTERN REGION

SUBJECT: Nondiscrimination in Services

TO: Patients/Clients/Residents/Parents

(►Insert one of the above, as applicable)

FROM:(►Insert Director’s Name and Signature)

Admissions, the provisions of services, and referrals of clients shall be made without regard to race, color, religious creed, disability, ancestry, national origin (including limited English proficiency), age, or sex.

Program services shall be made accessible to eligible persons with disabilities through the most practical and economically feasible methods available. These methods include, but are not limited to, equipment redesign, the provision of aides, and the use of alternative service delivery locations. Structural modifications shall be considered only as a last resort among available methods.

Any individual/client/patient/student (and /or their guardian) who believes they have been discriminated against, may file a complaint of discrimination with:

(►Insert Provider/Facility Name)

(►Insert Address)

Department of Public Welfare

PA Human Relations Commission

Bureau of Equal Opportunity

301 Fifth Avenue

Room 223, Health & Welfare Building

Suite 390, Piatt Place

625 Forster Street

Pittsburgh, PA 15222

Harrisburg, PA 17120

 

U. S. Department of Health and Human Services

Department of Public Welfare

Office for Civil Rights

Bureau of Equal Opportunity

Suite 372, Public Ledger Bldg.

Western Regional Office

150 South Independence Mall West

301 Fifth Avenue

Philadelphia, PA 19106

Suite 410, Piatt Place

 

Pittsburgh, PA 15222-1210

10