Ocrportal Hhs Gov Ocr Cp Complaint Confirmation Jsf

RE: 9926428

Thank you for filing a complaint via the website of the Office for Civil Rights (OCR) at theDepartment of Health and Human Services. This is an automated response toacknowledge receipt of your complaint. Your complaint will be assigned to an OCR staffmember for review and appropriate action. If OCR has any questions about the complaintyou submitted, we will contact you directly. Otherwise, you will receive a written responseindicating whether or not OCR has accepted your complaint for investigation.

Please do not fax, email, or mail a copy of this complaint to us as that may delaythe processing of your complaint.

If you have any additional information to add to your complaint, you may call1-800-368-1019. Please reference the number given by OCR when submitting yourcomplaint.

* Your First Name: charlene * Your Last Name: zechender

Phone:Phone Number Usage

(412) 366-4147 Home / CellStreet Address Line 1:* 103 lindley laneStreet Address Line 2:

* City: pgh*State:Pennsylvania Country:USA

* ZIP:15237

Email Address (If available):[email protected]

Are you filing this complaint for someone else?: No

* I believe that I have been (or someone else has been) discriminated againston the basis of::

Race / Color / National OriginReligionSex

Who or what agency or organization do you believe discriminated against you(or someone else)?

https://ocrportal.hhs.gov/ocr/cp/complaint_confirmation.jsf

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* Person or Agency/Organization?: Agency/OrganizationAgency/Organization: Eat'n Park Restaurants* Street Address Line 1: 930 Butler StreeStreet Address Line 2:

* City: Etna* State:Pennsylvania Country:USA ZIP: 15223

ZIP:Phone Number Usage(412) 487-4870 Work

* When do you believe that the civil right discrimination occurred?

Date(s) Selected:Violation Date

02/24/2015

Describe briefly what happened. How and why do you believe that you havebeen (or someone else has been) discriminated against? Please be as specificas possible.. (Attach additional pages as needed)i was talking about isis and the fate of our nation thehostess came over to me and told me to shut up this offendedme for i have every right to speech up about what is going onin my nation because i was talking about god they kicked meout of the Restaurant this is wrong for i have a right totalk this is my conitiuoin rights to talk about what ibelieve and to kick me out i want the hostess fired

Filing a complaint with OCR is voluntary. However, without the information requestedabove, OCR may be unable to proceed with your complaint. We collect thisinformation under authority of Title VI of the Civil Rights Act of 1964, Section 504 of theRehabilitation Act of 1973 and other civil rights statutes. We will use the informationyou provide to determine if we have jurisdiction and, if so, how we will process yourcomplaint. Information submitted on this form is treated confidentially and is protectedunder the provisions of the Privacy Act of 1974. Names or other identifying informationabout individuals are disclosed when it is necessary for investigation of possiblediscrimination, for internal systems operations, or for routine uses, which includedisclosure of information outside the Department of Health and Human Services(HHS) for purposes associated with civil rights compliance and as permitted by law. Itis illegal for a recipient of Federal financial assistance from HHS to intimidate,threaten, coerce, or discriminate or retaliate against you for filing this complaint or for


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taking any other action to enforce your rights under Federal civil rights laws.

You are not required to use this format. You may write a letter or mail a complaint withthe same information. To mail a complaint, please send to HHS Office for Civil Rights,Central Intake Unit, 200 Independence Avenue, S.W., Room 509 F, Washington, D.C.20201.

* Signature: AGREE: I have read, understand, and agree tothe above.

Do you need special accommodations for us to communicate with you aboutthis complaint?

Electronic mail

If we cannot reach you directly, is there someone we can contact to help usreach you?No entries

Have you filed your complaint anywhere else? If so, please provide thefollowing . (Attach additional pages as needed )

FiledElsewheres:

Person/Agency/Organization/Court Name Date Filed

Case Number (Ifknown)

No records found

To help us better serve the public, please provide the following information forthe person you believe was discriminated against (you or the person on whosebehalf you are filing).Ethnicity:

Race: White

Primary Language Spoken (if other than English):

How did you learn about the Office for Civil Rights?


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Religious/Community Org

COMPLAINANT CONSENT FORM

The Department of Health and Human Services' (HHS) Office for Civil Rights (OCR)has the authority to collect and receive material and information about you, includingpersonnel and medical records, which are relevant to its investigation of yourcomplaint.

To investigate your complaint, OCR may need to reveal your identity or identifyinginformation about you to persons at the entity or agency under investigation or to otherpersons, agencies, or entities.

The Privacy Act of 1974 protects certain federal records that contain personallyidentifiable information about you and, with your consent, allows OCR to use yourname or other personal information, if necessary, to investigate your complaint.

Consent is voluntary, and it is not always needed in order to investigate yourcomplaint; however, failure to give consent is likely to impede the investigation of yourcomplaint and may result in the closure of your case.

Additionally, OCR may disclose information, including medical records and otherpersonal information, which it has gathered during the course of its investigation inorder to comply with a request under the Freedom of Information Act (FOIA) and mayrefer your complaint to another appropriate agency.

Under FOIA, OCR may be required to release information regarding the investigationof your complaint; however, we will make every effort, as permitted by law, to protectinformation that identifies individuals or that, if released, could constitute a clearlyunwarranted invasion of personal privacy.

Please read and review the documents entitled, Notice to Complainants and OtherIndividuals Asked to Supply Information to the Office for Civil Rights and ProtectingPersonal Informations in Complaint Investigations for further information regardinghow OCR may obtain, use, and disclose your information while investigating yourcomplaint.

In order to expedite the investigation of your complaint if it is accepted byOCR, please read, sign, and returnone copy of this consent form to OCR withyour complaint. Please make one copy for your records.


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As a complainant, I understand that in the course of the investigation of mycomplaint it may become necessary for OCR to reveal my identity or identifyinginformation about me to persons at the entity or agency under investigation or toother persons, agencies, or entities.

I am also aware of the obligations of OCR to honor requests under the Freedomof Information Act (FOIA). I understand that it may be necessary for OCR todisclose information, including personally identifying information, which it hasgathered as part of its investigation of my complaint.

In addition, I understand that as a complainant I am covered by theDepartment ofHealth and Human Services' (HHS) regulations which protect any individual frombeing intimidated, threatened, coerced, retaliated against,or discriminatedagainst because he/she has made a complaint, testified, assisted, or participatedin any manner in any mediation, investigation, hearing, proceeding, or other partof HHS' investigation, conciliation, or enforcement process.

* Consent Selection:CONSENT: I have read, understand, and agree to the above andgive permission to OCR to reveal my identity or identifyinginformation about me in my case file to persons at the entityor agency under investigation or to other relevant persons,agencies, or entities during any part of HHS' investigation,conciliation, or enforcement process.

File Uploaded:File Name Size (Byte) File TypeNo records found


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Ocrportal Hhs Gov Ocr Cp Complaint Confirmation Jsf