Appendix A to Part 92 – Sample Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Sample Nondiscrimination Statement:
Discrimination is Against the Law
Jefferson Dental Clinics complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Jefferson Dental Clinics does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Jefferson Dental Clinics:
- 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 believe that Jefferson Dental Clinics has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Marti Diaz, Vice President of Human Resources, 3030 LBJ Freeway, Suite 1400, 972.663.5312 (phone), 972.663.5212 (fax),firstname.lastname@example.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Marti Diaz, Vice President of Human Resources, 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
Complaint forms are available at https://www.hhs.gov/ocr/filing-with-ocr/index.html.