Office for Civil Rights
Policy Examples
This section contains examples of policies that that you could use as guidance in developing civil rights policies and procedures for your facility. You may modify them to best reflect your procedures and methods.
Examples of Nondiscrimination Policies
Example One (for posting in the facility and inserting in advertising or admissions packages):
As a recipient of Federal financial assistance, (insert name of provider) does not exclude, deny benefits to, or otherwise discriminate against any person on the ground of race, color, or national origin, or on the basis of disability or age in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by (insert name of provider) directly or through a contractor or any other entity with which (insert name of provider) arranges to carry out its programs and activities.
This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Regulations of the U.S. Department of Health and Human Services issued pursuant to these statutes at Title 45 Code of Federal Regulations Parts 80, 84, and 91.
In case of questions, please contact:
Provider Name:
Contact Person/Section 504 Coordinator:
Telephone number:
TDD or State Relay number:
Example Two (for use in brochures, pamphlets, publications, etc.):
(Insert name of provider) does not discriminate against any person on the basis of race, color, national origin, disability, or age in admission, treatment, or participation in its programs, services and activities, or in employment. For further information about this policy, contact: (insert name of Section 504 Coordinator, phone number, TDD/State Relay).
Example of a Policy and Procedure for Providing Meaningful Communication with Persons with Limited English Proficiency
POLICY AND PROCEDURES FOR COMMUNICATION WITH PERSONS WITH LIMITED ENGLISH PROFICIENCY POLICY:
(Insert name of your facility) will take reasonable steps to ensure that persons with Limited English Proficiency (LEP) have meaningful access and an equal opportunity to participate in our services, activities, programs and other benefits. The policy of (Insert name of your facility) is to ensure meaningful communication with LEP patients/clients and their authorized representatives involving their medical conditions and treatment. The policy also provides for communication of information contained in vital documents, including but not limited to, waivers of rights, consent to treatment forms, financial and insurance benefit forms, etc. (include those documents applicable to your facility). All interpreters, translators and other aids needed to comply with this policy shall be provided without cost to the person being served, and patients/clients and their families will be informed of the availability of such assistance free of charge.
Language assistance will be provided through use of competent bilingual staff, staff interpreters, contracts or formal arrangements with local organizations providing interpretation or translation services, or technology and telephonic interpretation services. All staff will be provided notice of this policy and procedure, and staff that may have direct contact with LEP individuals will be trained in effective communication techniques, including the effective use of an interpreter.
(Insert name of your facility) will conduct a regular review of the language access needs of our patient population, as well as update and monitor the implementation of this policy and these procedures, as necessary.
PROCEDURES:
1. IDENTIFYING LEP PERSONS AND THEIR LANGUAGE
(Insert name of your facility) will promptly identify the language and communication needs of the LEP person. If necessary, staff will use a language identification card (or "I speak cards," available online at www.lep.gov) or posters to determine the language. In addition, when records are kept of past interactions with patients (clients/residents) or family members, the language used to communicate with the LEP person will be included as part of the record.
2. OBTAINING A QUALIFIED INTEPRETER
(Identify responsible staff person(s), and phone number(s)) is/are responsible for:
(a) Maintaining an accurate and current list showing the name, language, phone number and hours of availability of bilingual staff (provide the list);
(b) Contacting the appropriate bilingual staff member to interpret, in the event that an interpreter is needed, if an employee who speaks the needed language is available and is qualified to interpret;
(c) Obtaining an outside interpreter if a bilingual staff or staff interpreter is not available or does not speak the needed language.
(Identify the agency(s) name(s) with whom you have contracted or made arrangements) have/has agreed to provide qualified interpreter services. The agency's (or agencies') telephone number(s) is/are (insert number (s)), and the hours of availability are (insert hours).
Some LEP persons may prefer or request to use a family member or friend as an interpreter. However, family members or friends of the LEP person will not be used as interpreters unless specifically requested by that individual and after the LEP person has understood that an offer of an interpreter at no charge to the person has been made by the facility. Such an offer and the response will be documented in the person's file. If the LEP person chooses to use a family member or friend as an interpreter, issues of competency of interpretation, confidentiality, privacy, and conflict of interest will be considered. If the family member or friend is not competent or appropriate for any of these reasons, competent interpreter services will be provided to the LEP person.
Children and other clients/patients/residents will not be used to interpret, in order to ensure confidentiality of information and accurate communication.
3. PROVIDING WRITTEN TRANSLATIONS
(a) When translation of vital documents is needed, each unit in (insert name of your facility) will submit documents for translation into frequently-encountered languages to (identify responsible staff person). Original documents being submitted for translation will be in final, approved form with updated and accurate legal and medical information.
(b) Facilities will provide translation of other written materials, if needed, as well as written notice of the availability of translation, free of charge, for LEP individuals.
(c) (Insert name of your facility) will set benchmarks for translation of vital documents into additional languages over time.
4. PROVIDING NOTICE TO LEP PERSONS
(Insert name of your facility) will inform LEP persons of the availability of language assistance, free of charge, by providing written notice in languages LEP persons will understand. At a minimum, notices and signs will be posted and provided in intake areas and other points of entry, including but not limited to the emergency room, outpatient areas, etc. (include those areas applicable to your facility). Notification will also be provided through one or more of the following: outreach documents, telephone voice mail menus, local newspapers, radio and television stations, and/or community-based organizations (include those areas applicable to your facility).
5. MONITORING LANGUAGE NEEDS AND IMPLEMENTATION
On an ongoing basis, (insert name of your facility) will assess changes in demographics, types of services or other needs that may require reevaluation of this policy and its procedures. In addition, (insert name of your facility) will regularly assess the efficacy of these procedures, including but not limited to mechanisms for securing interpreter services, equipment used for the delivery of language assistance, complaints filed by LEP persons, feedback from patients and community organizations, etc. (include those areas applicable to your facility).
Example of a Policy and Procedure for Providing Auxiliary Aids for Persons with Disabilities
AUXILIARY AIDS AND SERVICES FOR PERSONS WITH DISABILITIES POLICY:
(Insert name of your facility) will take appropriate steps to ensure that persons with disabilities, including persons who are deaf, hard of hearing, or blind, or who have other sensory or manual impairments, have an equal opportunity to participate in our services, activities, programs and other benefits. The procedures outlined below are intended to ensure effective communication with patients/clients involving their medical conditions, treatment, services and benefits. The procedures also apply to, among other types of communication, communication of information contained in important documents, including waivers of rights, consent to treatment forms, financial and insurance benefits forms, etc. (include those documents applicable to your facility). All necessary auxiliary aids and services shall be provided without cost to the person being served.
All staff will be provided written notice of this policy and procedure, and staff that may have direct contact with individuals with disabilities will be trained in effective communication techniques, including the effective use of interpreters.
PROCEDURES:
1. Identification and assessment of need:
(Name of facility) provides notice of the availability of and procedure for requesting auxiliary aids and services through notices in our (brochures, handbooks, letters, print/radio /televison advertisements, etc.) and through notices posted (in waiting rooms, lobbies, etc.). When an individual self-identifies as a person with a disability that affects the ability to communicate or to access or manipulate written materials or requests an auxiliary aid or service, staff will consult with the individual to determine what aids or services are necessary to provide effective communication in particular situations.
2. Provision of Auxiliary Aids and Services:
(Insert name of your facility) shall provide the following services or aids to achieve effective communication with persons with disabilities:
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For Persons Who Are Deaf or Hard of Hearing
(i) For persons who are deaf/hard of hearing and who use sign language as their primary means of communication, the (identify responsible staff person or position with a telephone number) is responsible for providing effective interpretation or arranging for a qualified interpreter when needed.
In the event that an interpreter is needed, the (identify responsible staff person) is responsible for:
Maintaining a list of qualified interpreters on staff showing their names, phone numbers, qualifications and hours of availability (provide the list);
Contacting the appropriate interpreter on staff to interpret, if one is available and qualified to interpret; or
Obtaining an outside interpreter if a qualified interpreter on staff is not available. (Identify the agency(s) name with whom you have contracted or made arrangements) has agreed to provide interpreter services. The agency's/agencies' telephone number(s) is/are (insert number(s) and the hours of availability).
[Note: If video interpreter services are provided via computer, the procedures for accessing the service must be included.]
(ii) Communicating by Telephone with Persons Who Are Deaf or Hard of Hearing
[Listed below are three methods for communicating over the telephone with persons who are deaf/hard of hearing. Select the method(s) to incorporate in your policy that best applies/apply to your facility.]
(Insert name of facility) utilizes a Telecommunication Device for the Deaf (TDD) for external communication. The telephone number for the TDD is (insert number). The TDD and instructions on how to operate it are located (insert location) in the facility; OR
(Insert name of provider) has made arrangements to share a TDD. When it is
determined by staff that a TDD is needed, we contact (identify the entity e.g., library, school or university, provide address and telephone numbers); OR
(Insert name of facility) utilizes relay services for external telephone with TTY users. We accept and make calls through a relay service. The state relay service number is (insert telephone for your State Relay).
(iii) For the following auxiliary aids and services, staff will contact (responsible staff person or position and telephone number), who is responsible to provide the aids and services in a timely manner:
Note-takers; computer-aided transcription services; telephone handset amplifiers; written copies of oral announcements; assistive listening devices; assistive listening systems; telephones compatible with hearing aids; closed caption decoders; open and closed captioning; telecommunications devices for deaf persons (TDDs); videotext displays; or other effective methods that help make aurally delivered materials available to individuals who are deaf or hard of hearing.
(iv) Some persons who are deaf or hard of hearing may prefer or request to use a family member or friend as an interpreter. However, family members or friends of the person will not be used as interpreters unless specifically requested by that individual and after an offer of an interpreter at no charge to the person has been made by the facility. Such an offer and the response will be documented in the person's file. If the person chooses to use a family member or friend as an interpreter, issues of competency of interpretation, confidentiality, privacy and conflict of interest will be considered. If the family member or friend is not competent or appropriate for any of these reasons, competent interpreter services will be provided.
NOTE: Children and other residents will not be used to interpret, in order to ensure confidentiality of information and accurate communication.
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For Persons Who are Blind or Who Have Low Vision
(i) Staff will communicate information contained in written materials concerning treatment, benefits, services, waivers of rights, and consent to treatment forms by reading out loud and explaining these forms to persons who are blind or who have low vision [in addition to reading, this section should tell what other aids are available, where they are located, and how they are used].
The following types of large print, taped, Brailled, and electronically formatted materials are available: (description of the materials available). These materials may be obtained by calling (name or position and telephone number).
(ii) For the following auxiliary aids and services, staff will contact (responsible staff person or position and telephone number), who is responsible to provide the aids and services in a timely manner:
Qualified readers; reformatting into large print; taping or recording of print materials not available in alternate format; or other effective methods that help make visually delivered materials available to individuals who are blind or who have low vision. In addition, staff are available to assist persons who are blind or who have low vision in filling out forms and in otherwise providing information in a written format.
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For Persons With Speech Impairments
To ensure effective communication with persons with speech impairments, staff will contact (responsible staff person or position and telephone number), who is responsible to provide the aids and services in a timely manner:
Writing materials; typewriters; TDDs; computers; flashcards; alphabet boards; communication boards; (include those aids applicable to your facility) and other communication aids.
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For Persons With Manual Impairments
Staff will assist those who have difficulty in manipulating print materials by holding the materials and turning pages as needed, or by providing one or more of the following:
note-takers; computer-aided transcription services; speaker phones; or other effective methods that help to ensure effective communication by individuals with manual impairments. For these and other auxiliary aids and services, staff will contact (responsible staff person or position and telephone number) who is responsible to provide the aids and services in a timely manner.
Example of a Notice of Program Accessibility for Describing that your Program is Accessible to Persons with Disabilities
Section 504 Notice of Program Accessibility
The regulation implementing Section 504 requires that an agency/facility "…adopt and implement procedures to ensure that interested persons, including persons with impaired vision or hearing, can obtain information as to the existence and location of services, activities, and facilities that are accessible to and usable by disabled persons." (45 C.F.R. §84.22(f))
(Insert name of facility) and all of its programs and activities are accessible to and useable by disabled persons, including persons who are deaf, hard of hearing, or blind, or who have other sensory impairments. Access features include:
- Convenient off-street parking designated specifically for disabled persons.
- Curb cuts and ramps between parking areas and buildings.
- Level access into first floor level with elevator access to all other floors.
- Fully accessible offices, meeting rooms, bathrooms, public waiting areas, cafeteria, patient treatment areas, including examining rooms and patient wards.
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A full range of assistive and communication aids provided to persons who are deaf, hard of hearing, or blind, or with other sensory impairments. There is no additional charge for such aids. Some of these aids include:
- Qualified sign language interpreters for persons who are deaf or hard of hearing.
- A twenty-four hour (24) telecommunication device (TTY/TDD) which can connect the caller to all extensions within the facility and/or portable (TTY/TDD) units, for use by persons who are deaf, hard of hearing, or speech impaired.
- Readers and taped material for the blind and large print materials for the visually impaired.
- Flash Cards, Alphabet boards and other communication boards.
- Assistive devices for persons with impaired manual skills.
If you require any of the aids listed above, please let the receptionist or your nurse know.
Example of a Section 504 Grievance Procedure that Incorporates Due Process Standards
Section 504 GRIEVANCE PROCEDURE It is the policy of (insert name of facility/agency) not to discriminate on the basis of disability. (Insert name of facility/agency) has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794) or the U.S. Department of Health and Human Services regulations implementing the Act. Section 504 states, in part, that "no otherwise qualified handicapped individual...shall, solely by reason of his handicap, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance..." The Law and Regulations may be examined in the office of (insert name, title, tel. no. of Section 504 Coordinator), who has been designated to coordinate the efforts of (insert name of facility/agency) to comply with Section 504.
Any person who believes she or he has been subjected to discrimination on the basis of disability may file a grievance under this procedure. It is against the law for (insert name of facility/agency) to retaliate against anyone who files a grievance or cooperates in the investigation of a grievance.
Procedure:
Grievances must be submitted to the Section 504 Coordinator within (insert timeframe) of the date the person filing the grievance becomes aware of the alleged discriminatory action.
A complaint must be in writing, containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought.
The Section 504 Coordinator (or her/his designee) shall conduct an investigation of the complaint. This investigation may be informal, but it must be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 504 Coordinator will maintain the files and records of (insert name of facility/agency) relating to such grievances.
The Section 504 Coordinator will issue a written decision on the grievance no later than 30 days after its filing.
The person filing the grievance may appeal the decision of the Section 504 Coordinator by writing to the (Administrator/Chief Executive Officer/Board of Directors/etc.) within 15 days of receiving the Section 504 Coordinator's decision.
The (Administrator/Chief Executive Officer/Board of Directors/etc.) shall issue a written decision in response to the appeal no later than 30 days after its filing.
The availability and use of this grievance procedure does not prevent a person from filing a complaint of discrimination on the basis of disability with the U. S. Department of Health and Human Services, Office for Civil Rights.
(Insert name of facility/agency) will make appropriate arrangements to ensure that disabled persons are provided other accommodations if needed to participate in this grievance process. Such arrangements may include, but are not limited to, providing interpreters for the deaf, providing taped cassettes of material for the blind, or assuring a barrier-free location for the proceedings. The Section 504 Coordinator will be responsible for such arrangements.
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