DISCRIMINATION COMPLAINT FORM
for residents of an RHC

NAME  _____________________________________________
PHONE NUMBER __________________________________

I LIVE AT:   	___ RAINIER			___ FIRCREST

			___ YAKIMA VALLEY	___ LAKELAND

			___ FRANCES HADDEN MORGAN
		IN HOUSE OR UNIT ____________________

___ I want to move out of here and live in the community under 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
Filing an Olmstead Complaint - page 2