LifeSpring Health Systems Title VI Complaint Form

LifeSpring Health Systems Title VI Complaint Form SectionI:
Name:
Address:
Telephone(Home):
Telephone(Work):
ElectronicMailAddress:
AccessibleFormatRequirements?
LargePrint
TDD
AudioTape
Other
SectionII:
Areyoufilingthiscomplaintonyourownbehalf?
Yes*
No
*Ifyouanswered"yes"tothisquestion,gotoSectionIII.
Ifnot,pleasesupplythenameandrelationshipofthepersonforwhomyouare
complaining:
Pleaseexplainwhyyouhavefiledforathirdparty:
Pleaseconfirmthatyouhaveobtainedthepermissionoftheaggrievedpartyif
youarefilingonbehalfofathirdparty.
Yes
No
SectionIII:
IbelievethediscriminationIexperiencedwasbasedon(checkallthatapply):
[]Race[]Color[]NationalOrigin[]Sex
[]Age[]Disability[]LowIncome
DateofAllegedDiscrimination(Month,Day,Year):
__________
Explainasclearlyaspossiblewhathappenedandwhyyoubelieveyouwerediscriminatedagainst.Describe
allpersonswhowereinvolved.Includethenameandcontactinformationoftheperson(s)who
discriminatedagainstyou(ifknown)aswellasnamesandcontactinformationofanywitnesses.Ifmore
spaceisneeded,pleaseusethebackofthisform.
___________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
SectionIV
HaveyoupreviouslyfiledaTitleVIcomplaintwiththis
agency?
Yes
No
SectionV
HaveyoufiledthiscomplaintwithanyotherFederal,State,orlocalagency,orwithanyFederalorState
court?
[]Yes
[]No
Ifyes,checkallthatapply:
[]FederalAgency: []FederalCourt
[]StateAgency
[]StateCourt
[]LocalAgency
Pleaseprovideinformationaboutacontactpersonattheagency/courtwherethecomplaintwasfiled.
Name:
Title:
Agency:
Address:
Telephone:
SectionVI
Nameofagencycomplaintisagainst:
Contactperson:
Title:
Telephonenumber:
You may attach any written materials or other information that you think is relevant to your complaint. Signature and date required below _____________________________________ ________________________ Signature Date Please submit this form in person at the address below, or mail this form to: Corporate Compliance Officer Department of Performance Improvement 460 Spring Street Jeffersonville, IN 47130 LifeSpring Health Systems Title VI Procedures Title VI of the 1964 Civil Rights Act requires that “No person in the United States shall, on the grounds of race, color or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.” Any person who believes that he/she has been aggrieved by an unlawful discriminatory practice on the basis of race, color or national origin by Corporate Compliance Officer may file a complaint by completing and submitting Corporate Compliance Officer the Title VI Complaint form. How do you file a complaint? You may download the Title VI Complaint Form at www.lifespringhealthsystems.org, or request a copy by writing or phoning LifeSpring Health Systems Department of Performance Improvement, 460 Spring Street, Jeffersonville, IN 47130 phone/812‐280‐2080. You may file a signed, dated and written complaint no more than 180 days from the date of the alleged incident. The complaint should include: ‐ Your name, address and telephone number. ‐ How, why, and when you believe you were discriminated against. Include as much specific, detailed information as possible about the alleged acts of discrimination, and any other relevant information. ‐ The names of any persons, if known, whom the director could contact for clarity of your allegations. Please submit your complaint form to address listed below: Corporate Compliance Officer Department of Performance Improvement LifeSpring Health Systems 460 Spring Street Jeffersonville, IN 47130 How will your complaint be handled? LifeSpring Health Systems investigates complaints received no more than 180 days after the alleged incident. LifeSpring will process complaints that are complete. Once a completed complaint is received, LifeSpring will review it to determine if LifeSpring has jurisdiction. The complainant will receive an acknowledgement letter informing her/him whether the complaint will be investigated by LifeSpring Health Systems. LifeSpring Health Systems will generally complete an investigation within 90 days from receipt of a completed complaint form. If more information is needed to resolve the case, LifeSpring may contact the complainant. Unless a longer period is specified by LifeSpring, the complainant will have ten (10) days from the date of the letter to send requested information to the LifeSpring Health Systems investigator assigned to the case. If a LifeSpring Health Systems investigator is not contacted by the complainant or does not receive the additional information within the required timeline, LifeSpring may administratively close the case. A case may be administratively closed also if the complainant no longer wishes to pursue their case. After an investigation is complete, LifeSpring Health Systems will issue a letter to the complainant summarizing the results of the investigation, stating the findings and advising of any corrective action to be taken as a result of the investigation. If a complainant disagrees with LifeSpring, he/she may request reconsideration by submitting a request in writing to LifeSpring Health Systems President/CEO within seven (7) days after the date of a letter, stating with specificity the basis for the reconsideration. The President/CEO will notify the complainant of his decision either to accept or reject the request for reconsideration within 10 days. In cases where reconsideration is granted, the President/CEO will issue a determination letter to the complainant upon completion of the reconsideration review. A person may also file a complaint directly with the Federal Transit Administration, at FTA Office of Civil Rights, 1200 New Jersey Avenue SE, Washington, DC 20590. If information is needed in another language, please contact LifeSpring Health Systems at 812‐
280‐2080.