DISCRIMINATION COMPLAINT FORM
for residents of Eastern or Western State Hospital

NAME  _____________________________________________
PHONE NUMBER __________________________________

I LIVE AT:   	___ Western State Hospital

			___ Eastern State Hospital

			______________________ other 
		ON WARD OR UNIT ____________

_____  I want to move out of here and live in the community pursuant to Olmstead

I was treated differently because of my:  	

___ Gender	___ Race		___ Religion	___ Age 									
___ Disability	___  Other Reason

WHAT HAPPENED?
_______________________________________________________________________________________________________________________________________________________________________________________
Person to Contact and Phone Number:
_____________________________________________________________

Signature:

Mail this form to:	Office for Civil Rights
US Department of Health and Human Services
2201 Sixth Avenue, M/S: RX-11
Seattle, WA 98121