STATE OF FLORIDA

DEPARTMENT OF HEALTH

CIVIL RIGHTS COMPLIANCE CHECKLIST

For the Fiscal Year July 1 2013 to June 30, 2014

Facility / Program	County
Address	Completed By
City, State, Zip Code	Date	Telephone

Briefly describe the geographic area served by the program/facility and the type of services provided:

Minimum Requirements	Complies?	N/A	COMMENTS If, No or N/A, Explain briefly	Local - County procedures or policy refs
Yes	No
Requirement: DOH Policy – Designation of Compliance Officer. Programs and facilities that employ 15 or more persons must designate at least one person to coordinate efforts to comply with the requirements of Title VI of the Civil Rights Act of 1964 (Title VI); HHS Assurances; as well as Section 504 of the Rehabilitation Act of 1972 (Section 504), the ADA of 1990 (ADA), and the Age Discrimination Act of 1975.
1. Has your organization assigned the local responsibility for insuring compliance with the HHS Assurances for Title VI of the Civil Rights Act of 1964 (Title VI), as amended, under the contract between the Florida Department of Health and the U.S. Department of Health and Human Services to someone in your organization?	Y	N
1a. Who is designated as the local Title VI Coordinator?
1b. What is this person’s position title?
2. Have all contracted service providers with 15 or more employee designated a Title VI Coordinator?	Y	N
a Section 504 coordinator:	Y	N
a contact person for ADA and Limited English Proficiency (LEP) requests	Y	N
3. Has your organization appointed an employee with compliance monitoring responsibilities for Section 504, ADA, and the Age Discrimination Act of 1975? If not the same as the Title VI coordinator (#1 above), provide the name, position title and contact information.	Y	N
Requirement: DOH Policy – Equal Access and Participation (Participation). Programs and facilities will maintain and record statistics which will document equal access and participation in compliance with Title VI, including participant demographics and program qualification requirements, including numbers applying for services, enrollment, and number not enrolled.

Requirement – Equal Access and Participation: Reporting Community Outreach and Advocacy
4. Does your organization document the dissemination of information to the community (including clients, potential clients and advocacy groups) about HHS’s Title VI programs and your organization’s commitment to compliance with civil rights and non-discrimination?	Y	N
4.a – Does your organization regularly meet or communicate with community organizations and advocacy groups?	Y	N
4.b – What community organizations and advocacy groups do you communicate regularly with, and how? (List on a separate sheet)	Y	N

Requirement – Equal Access and Participation: Reporting Compliance
5. Does your organization record and maintain statistics which will document equal access and participation in compliance with Title VI ?	Y	N
5.a – Do your records identify participants and applicants in each program at each center or location, and if so, do you record race, color, national origin, age, gender and disability status?	Y	N
5.b – Are the participation rates reported to the EO Section – and how often?	Y	N
5.c – Do you report the number and enrollment rates of applicants and the number of participants who complete each program?	Y	N
5.d – Do you offer and collect participant satisfaction surveys for each program?	Y	N
5.e – Who has physical custody of the records on applicants and participants, and surveys?	Y	N

Requirement - Equal Access and Participation: Limited English Proficiency and Auxiliary Aids Plan
6. Does your organization annually review the Department’s LEP and Auxiliary Aids Plan (LEP/AA) and incorporate any changes in the local LEP/AA Plan provisions?	Y	N
6.a Who is designated as the LEP/AA Plan contact and coordinator?	(Name, Title and Phone number)

6.b Does the above individual annually review and update the local resources and referrals for your organization?	Y	N

Requirement - Equal Access and Participation: Communications
6.c Does your organization provide an updated list of local resources and referrals to staff and/or training, to provide information on how to access the list of resources? If so, does it include the following:	Y	N
6.c.1. Description of auxiliary aids available for use in each phase of the service delivery process	Y	N
6.c.3. Does the organization have a requirement for training for direct services field staff, institutional staff and other staff who deal with the public? If so, does it include the following:	Y	N
6.c.3a. Procedures to be used by direct service staff in requesting appropriate auxiliary aids	Y	N
6.c.3b. Florida Relay Service (FRS) phone number (711) publicized for communications	Y	N
6.c.3c. Full range of communication options, at no cost	Y	N
6.c.3d. A list of formal arrangements with interpreters who can accurately and fluently express and receive in sign language? The names, addresses, phone numbers and hours of availability of interpreters must be readily available to direct services employees.	Y	N
6.c.3e. – Accessibility to supplemental hearing devices as needed.	Y	N
6.c.3f. - Use of written communication in lieu of verbal communications.	Y	N
6.c.3g. – Use of Flash cards to communicate.	Y	N
6.c.3h. At least one telecommunications device, or an arrangement to share a TDD line with other facilities.	Y	N
6.c.4. Information that use of family members may be used only if they are specifically requested by a hearing impaired person.	Y	N

7. Does the organization have a written Monitoring Procedure which includes:
- Description of how client needs are assessed.	Y	N
- Approval responsibility for request for and obtaining the requested auxiliary aid or interpreter	Y	N
- Standard time for DOH to provide service(s)	Y	N
- FRS phone number (711) publicized	Y	N
- Name of CHD/CMS Director or Administrator is provided and displayed	Y	N
- Name and contact information for local EO Coordinator, ADA Coordinator and to request LEP/AA Plan services displayed in each location	Y	N
Name and contact information for the DOH EO Manager is provided and displayed	Y	N
-. A procedure (including Poster) for notifying clients and applicants of the availability of auxiliary aids and procedures for requesting an auxiliary aid	Y	N
7a - List of Locations where DOH Posters have been posted; and when the last On-site was done to ascertain Posters are visible and current?	Y	N
7b - Training and Meeting Notices contain required contact information to request services	Y	N

Requirement: DOH Policy - Notice of Title VI Rights and Complaint Procedures – Programs/facilities must make available to their participants, beneficiaries or any other interested parties information on their right to file a complaint of discrimination with either the Florida Department of Health or the United States Department of Health and Human Services (HHS). The information may be supplied verbally or in writing to every individual, or may be supplied through the use of an equal opportunity policy poster displayed in public areas of the facility.
8. Does your organization inform participants, beneficiaries or other interested parties of their right to file a complaint of discrimination with either the DOH or the U S Department of Health and Human Services (HHS)?	Y	N
8a – How do you inform and instruct your employees and provider personnel of the commitment to compliance with federal regulations regarding nondiscrimination?	Y	N
8b – Do you have an established procedure for reporting internal grievance or complaints for possible discrimination or civil rights violations?	Y	N

8c – Have your local procedures been reviewed and approved by the DOH EO Section?	Y	N
8d – Has your organization provided all participants or applicants for services with contact information for the state Equal Opportunity office (EO Section) in Tallahassee?	Y	N
8e – Have your employees or applicants for employment been provided with contact information for the Department Equal Opportunity office (EO Section) in Tallahassee and informed of their right to file a discrimination complaint ?	Y	N
8f – Is there a written record made of information regarding a person’s request to file a complaint and who provided it?	Y	N
8g. Does your organization ensure the EO Section is informed of any report by a client or employee of possible or alleged violation of discrimination laws within recommended time frames?	Y	N

Requirement: DOH Policy - Reporting Requirements: Self-Evaluation (Physical Accessibility). Programs and facilities must conduct a self-evaluation to identify any accessibility barriers, using the four step process that includes (1) evaluate current practices and policies to identify any that do not complaint with Section 504 or the ADA; modify policies and practices that do not meet requirements; take remedial steps to eliminate any discrimination that has been identified; and maintain the self-evaluation on file. Assure the program/facility is physically accessible to disabled individuals. Physical accessibility includes designated parking areas, curb cuts or level approaches, ramps and adequate width to entrances. The lobby, public telephone, restroom facilities, water fountains, information and admissions offices should be accessible. Door widths and traffic areas of administrative offices, cafeterias, restrooms, recreation areas, counters and serving lines should be observed for accessibility. Switches and controls for light, heat, ventilation, fire alarms, and other essentials should be installed at an appropriate height for accessibility for mobility-impaired individuals.
9. Has your organization, and each program, conducted and submitted a self-evaluation in the past three to five years? (Forms: Program Self-Evaluation, Communication Access, and an ADA Facility Accessibility Checklist(s))	Y	N
9a –Has a copy of each completed self-evaluation been provided to the compliance officer and the DOH EO Section?	Y	N
9b – Has there been any new construction or renovation work done on the facility in which the programs are provided since the last self-evaluation?	Y	N
9c – Was a self-evaluation completed following completion of the work or provided by the contractor	Y	N
9d – Has your organization identified any areas in which compliance should or could be improved?	Y	N
9e – What has the organization done to address previous compliance issues or to improve compliance in the previous year?	Y	N

Requirement: DOH Policy - Reporting Requirements: Training.
10. Has the local compliance officer or designee completed DOH’s EO training in the last 3 years?	Y	N
10a. Have all employees completed DOH’s orientation to EO rights: in New Hire training, or in the last 3 years, or when new policies or procedures have been promulgated?	Y	N
Requirement: DOH Policy- Reporting Requirements: Staff Recruitment and Selection
11. Are recruitment and selection files maintained for not less than two years after the selection is processed?	Y	N
12. Do recruitment announcements include the “Equal Employment Opportunity” nondiscrimination statement (tagline) in all job vacancy announcements?	Y	N
13. Is there any written guidance regarding advertising position vacancies in local newspapers? In minority newspapers?	Y	N
14. Are other methods used to publicize job vacancies? If so, describe.	Y	N