Connecticut WIC Program Manual WIC 104-03 SECTION: Civil Rights SUBJECT: Discrimination Complaints Federal Regulations: §246.8 (b), FNS Instruction 113-1, Departmental Regulation 4300-003, Equal Opportunity Public Notification Policy-June 2, 2015
POLICY Any individual who applies to or participates in the WIC program has the right to file a discrimination complaint. Applicants and participants must be advised at the service delivery point of their right to file a complaint, how to file a complaint, and the complaint procedures.
Complaints Processed by the State
The State agency will process inquiries/complaints alleging discrimination based on: ancestry, marital status, religious creed, sexual orientation, lawful source of income and gender identity or expression.
Inform the applicant or participant of any alternative avenues of redress and provide them a copy of the Discrimination Complaint Procedure and Form.
The complaint procedure is as follows:
1. Applicants or participants may file complaints of alleged discrimination with the Local Agency or directly to DPH Equal Opportunity Officer and DPH State WIC Program Monitor.
2. Complaints filed at the Local Agencies must be directed or submitted to the following State contact points within 24 hours and the party alleging discrimination must be given the list of alternative avenues of redress.
3. The Equal Opportunity Officer may endeavor to mitigate or resolve any complaint at the lowest level possible and all records of complaints shall be maintained and reviewed on a regular basis by the DPH Equal Opportunity Officer to detect any patterns in the nature of these complaints.
4. The Equal Opportunity Officer will periodically review informal resolutions to assure that the agreement has been fulfilled and/or that no retaliatory actions have been taken by either party.
5. All complaints shall be processed within 90 days of receipt to ensure alternate avenues of redress are not foreclosed.
Local agencies receiving complaints must submit a copy of the Discrimination Complaint Form, via fax, within 24 hours to attention of both:
Equal Opportunity Officer WIC Program Monitor State of Connecticut, DPH State of Connecticut, DPH 410 Capitol Avenue, MS#13AFA 410 Capitol Avenue, MS#11WIC P.O. Box 340308 P.O. Box 340308 Hartford, CT 06134-0308 Hartford, CT 06134-0308 Fax# 860-509-7111 Fax# 860- 509-8391
Complaints Processed by USDA - Food and Nutrition Service
USDA – Food and Nutrition Service will process complaints of discrimination on the basis of: race, color, national origin, age, sex, or disability.
The complaint procedure is as follows:
1. Applicants and/or participants who request information regarding the Civil Rights complaint process, including a statement indicating they wish to file a Civil Rights complaint on one or more of the Federally protected bases, will be advised and provided the information included in the USDA Nondiscrimination Statement.
2. However, all complaints citing one or more of the Federally protected bases must be directed or submitted to the contact points in the Nondiscrimination Statement (see below) within 24 hours and the party alleging discrimination must be given the list of alternative avenues of redress.
Nondiscrimination Statement In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11- 28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by: 1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or 2) fax: (833) 256-1665 or (202) 690-7442; or 3) email: program.intake@usda.gov.
This institution is an equal opportunity provider.
Complainant Protection Any individual who has made a discrimination complaint, formal allegation, testified, assisted, or participated in an investigation or proceeding shall not be intimidated, threatened, coerced, or discriminated against.
Confidentiality The identity of every complainant shall be kept confidential except to the extent necessary to carry out the purpose of this part, including the conducting of any investigation, hearing, or judicial proceeding.
Discrimination Complaint Procedure (WIC et.al.) This Discrimination Complaint Procedure covers alleged discrimination on the basis of; race, color, national origin, age, sex, disability and ancestry, marital status, religious creed, sexual orientation, lawful source of income, gender identity or expression and disability as defined by the Americans with Disabilities Act, Amendments Act, 2008 (ADAAA). Any person-alleging discrimination on the basis of race, age2 disability, color, sex or national origin may file a complaint directly with the USDA within 180 days of the alleged discriminatory action.
The filing of a discrimination complaint shall in no way affect future considerations of eligibility or participation.
The Local Agency, DPH State WIC Program Monitor and USDA shall treat confidentiality as essential to the successful implementation of discrimination complaint processing. As such, when involved in such complaints, disclosure of information relating to the nature of the complaint and the identity of the grievant will be on a “need to know” basis, both inside and outside the Local Agency. Rights under the Privacy Act, 1974 will be stressed at all times and records retained shall be confidential except where disclosure is required by law.
Protection of Rights Provision
1. Any person who willfully interferes with or otherwise impairs the processing of any complaints taken under this policy, or in any way restricts or impairs the civil rights of the applicant/participant or any witness involved, will be subject to non-compliance sanctions.
2. The confidentiality of all investigations and counseling will be protected by the issuance of this policy.
3. This procedure shall not be construed as having the effect of barring any person from due process of law. If any person feels that he/she has been treated in a discriminatory manner; a complaint may be filed directly with the Connecticut Commission on Human Rights and Opportunities, the United States Equal Employment Opportunity Commission, United States Department of Agriculture/Food and Nutrition Services, the United States Department of Health and Human Services or any other state, federal, or local agency that enforces laws concerning discrimination in public service or public accommodation.
4. Any individual or witness may informally bring forth a claim of alleged discrimination or harassment without following the above prescribed discrimination complaint procedure, as complaints may be Written – by the applicant or client, Oral – in which case the LA staff person would write for the applicant/client or Anonymous-staff should file this paperwork also.
WIC STATE & FEDERAL DISCRIMINATION COMPLAINT AGENCIES
An individual has the right to file his or her complaint of discrimination with any or all of the relevant agencies listed below. The individual can also simultaneously avail himself or herself of this Department of Public Health’s Discrimination Complaint Procedure.
1. The Connecticut Commission on Human Rights & Opportunities Complaints should be filed with the Commission on Human Rights and Opportunities no later than one hundred and eighty (180) days after the alleged act of discrimination occurred.
2. CT District Office, United States Labor Department Wage and Hour Division 135 High Street Hartford, CT 06103 Tel: (860) 240-4277
3. Nondiscrimination Statement In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the responsible state or local agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-0002-508-11- 28-17Fax2Mail.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to USDA by: 1. mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; or 2. fax: (833) 256-1665 or (202) 690-7442; or 3. email: program.intake@usda.gov This institution is an equal opportunity provider. Documentation of Civil Rights Complaints
The Local agency must maintain a record of all Civil Rights complaints received. The Civil Rights complaint log must be maintained and available upon request by State Monitors
AD-3027 OMB Control No: 0508-0002 Expiration Date: 09/30/2027 U.S. Department of Agriculture USDA Program Discrimination Complaint Form
Complainant Information First name Middle Initial Last Name Mailing Address (Include Full City, State and Zip Code) Primary Phone Number Alternate Phone Number Email Best way to reach you: ☐ Mail ☐ Phone ☐ Email ☐ Other If you have difficulty understanding the English language, you may request language assistance services by calling 866-632-9992. Assistance will be available for individuals who are not proficient in English. Persons with disabilities who require alternative means of communication (e.g., braille, large print, American Sign Language) should contact the responsible State or local Agency that administers the program or contact the United States Department of Agriculture (USDA) through the Federal Telecommunications Relay Service at 711 (voice TTY). Representative Information Do you have a representative? ☐ Yes ☐ No Do you have written authorization from representative? If so, please attach. ☐ Yes ☐ No First name Last Name Mailing address (Include Full City, State and Zip Code) Phone Email Complaint Information (attach additional pages and supporting documentation as needed) 1. Provide the name of the program you applied for (if known/applicable). 2. Select the USDA agency that conducts the program or provides Federal financial assistance for the program. ☐ Agricultural Marketing Service, AMS ☐ Foreign Agricultural Service, FAS/Trade and Foreign Agricultural Affairs, TFAA ☐ Food and Nutrition Service, FNS ☐ Forest Service, FS ☐ Farm Service Agency, FSA ☐ National Institute of Food and Agriculture, NIFA ☐ Natural Resources Conservation Service, NRCS ☐ Rural Development, RD ☐ Other ☐ Unknown 3. Date of recent alleged discrimination (mm/dd/yyyy) 4. Location and/or address of the office where discrimination occurred 5. Who do you believe discriminated against you? Include the name(s) of person(s) involved in the alleged discrimination (if known).
AD-3027 OMB Control No: 0508-0002 Expiration Date: 09/30/2027 U.S. Department of Agriculture USDA Program Discrimination Complaint Form
6. What happened to you (please include dates of each allegation)? 7. It is a violation of the law to discriminate against you based on the following: race, color, national origin, religion, sex including gender identity and expression, sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, and political beliefs. (Not all bases apply to all programs). Reprisal is prohibited based on prior civil rights activity.
I believe I was discriminated against based on: ☐ Race ☐ Sex ☐ Marital Status ☐ Sexual Orientation ☐ Gender Identity (Expression) ☐ Color ☐ Disability ☐ Family/Parental Status ☐ National Origin ☐ Age ☐ Income from Public Assistance ☐ Political Beliefs ☐ Religion ☐ Retaliation (prior civil rights activity) Remedies 8. How would you like to see this complaint resolved? 9. Have you filed a complaint about the incident(s) with another federal, state, or local agency or with a court? 10. If yes, with what agency or court did you file? 11. If yes, when did you file? (mm/dd/yyyy)
Complainant Signature Date Representative Signature Date
AD-3027 OMB Control No: 0508-0002 Expiration Date: 09/30/2027
INSTRUCTIONS PURPOSE: The Agriculture Department 3027(AD 3027) Program Discrimination Complaint Form may be used to file a complaint if you believe you have experienced discrimination in any USDA program or activity, and you wish to file a complaint of discrimination. The form can be used to file a complaint of discrimination based on race, color, national origin (including limited English proficiency), religion, sex (including gender identity and expression), sexual orientation, disability, age, marital status, family/parental status, income derived from public assistance program and political beliefs. You may also use this form to file a program complaint alleging an adverse environmental impact to your health or the environment of a protected group caused by the program or activities of USDA, its Mission Areas or agencies. You are not required to use this form to file a discrimination complaint, you may send a letter or email instead of this form. The letter or email must include the information requested in items 1-11 on this form. If you decide to use this form, please type or print all information in items 1-11 of this form and use additional pages if more space is needed. If you need assistance completing this form, call 866-632-9992.
Pursuant to 7 CFR 16.4(d), beneficiaries and prospective beneficiaries in programs supported by indirect financial assistance from USDA may file written complaints with USDA alleging violations of the rule’s religious freedom protections by contacting or filing a written complaint with USDA’s Office of the Assistant Secretary for Civil Rights (OASCR). If you need assistance filling out this form (including translation services), you may call (866) 632-9992; assistance will be available in English and for individuals who are not proficient in English or in other languages. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, and American Sign Language) should contact the responsible State or local Agency that administers the program or contact USDA through the Telecommunications Relay Service at 711 (voice and TTY) We must have a signed copy of your complaint. An incomplete or unsigned form or letter will delay processing of your complaint. FILING DEADLINE: A program discrimination complaint must be filed within 180 days from the date you knew or should have known of the alleged discrimination unless the time for filing is extended by USDA. Complaints sent by mail are considered filed on the date the complaint is received by USDA. Complaint documentation or Complaint Forms sent by email will be considered filed on the date the complaint is received. Complaints filed after the 180-day deadline must include a ‘good cause’ explanation for the delay. For example, if: 1. You could not reasonably have been expected to know of the discriminatory act within the 180-day period; 2. You were seriously ill or incapacitated; or 3. The same complaint was filed with another Federal, state, or local agency and that agency failed to act on your complaint. USDA POLICY: Federal law and policy prohibit discrimination against you based on race, color, and national origin includes discrimination based on shared ancestry or ethnic characteristics or based on citizenship in a country with a dominant religion. Discrimination based on race, color, and national origin also includes discrimination, including harassment, because you and/or another individual are, for example, Jewish, Muslim, Arab, Hindu, or Sikh; or based on other ethnic and religious characteristics. For example, individuals who have been subjected to ethnic slurs (such as antisemitic or anti-Muslim harassment); harassed for how they look, dress, or speak in ways related to their ethnic background (such as skin color, religious attire, or language spoken); or stereotyped based on their perceived ethnic characteristics. USDA will determine if it has jurisdiction under the law to process the complaint on the basis identified in the complaint and in the programs indicated in the complaint. Reprisal that is based on prior civil rights activity is prohibited.
AD-3027 OMB Control No: 0508-0002 Expiration Date: 09/30/2027
WHERE TO FILE YOUR COMPLAINT: You may submit your completed form or letter to USDA by: Mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence, Ave, SW, Mail Stop 9410, Washington, DC 20250-9410. e-Mail: program.intake@usda.gov.
For more information visit: https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complaint. LEGAL INFORMATION CONSENT: This USDA Program Discrimination Complaint Form is provided in accordance with the Privacy Act of 1974 (5 U.S.C. §552a) and is used to solicit information for processing complaints of discrimination. USDA requests this information pursuant to 7 CFR Part 15. If the completed form is accepted as a complaint, the information collected during the investigation will be used to process your program discrimination complaint. RETALIATION PROHIBITED: No Agency, officer, employee, or agent of the USDA, including persons representing the USDA and its programs, shall intimidate, threaten, harass, coerce, discriminate against, or otherwise retaliate against anyone who has filed a complaint of alleged discrimination or who participates in any manner in an investigation or other proceeding raising claims of discrimination. PRIVACY ACT STATEMENT( 5 U.S.C. § 552a) AUTHORITIES: Collection of this information is authorized by Title VI of the Civil Rights Act of 1964 (42 U.S.C. § 2000d); and Sections 504 and 508 of the Rehabilitation Act of 1973 (29 U.S.C. §§ 794; 794d) and any other anti- discrimination statutes, rules and regulations. PURPOSE: The information solicited on this form is used for processing complaints of discrimination under the statutes listed in the "Authorities" section of this notice. Any information obtained from this form will be maintained in our system of record. ROUTINE USES: More information on the routine uses for the system can be found in the System of Records Notice USDA-2021-0007 records maintained by OASCR can be seen via the internet at https://www.usda.gov/home/privacy-policy/system-records-notices. DISCLOSURE: Providing this information is voluntary. Failure to complete this form may lead to a delay in processing of the complaint or rejection of the complaint due to an inadequate information to continue processing. PAPERWORK REDUCTION ACT STATEMENT The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.) requires us to inform you that this information is being collected to ensure that your complaint contains all the information required to process it fully. OASCR will use the information to process your discrimination complaint. Response to this request is voluntary. The information you provide on this form will only be shared with persons who have an official need to know and will be protected from public disclosure pursuant to the provisions of the Privacy Act, (5 U.S.C. § 552a(b)). The estimated time required to complete this form is 60 minutes. You may send comments regarding the accuracy of this estimate and any suggestions for reducing the time for completion of the form to the U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Mail Stop 9410, DC 20250-9410. An agency may not conduct or sponsor, nor is a person required to respond to, a collection of information unless it displays a currently valid OMB Control Number. The OMB Control Number for this form is 0508-0002.
AD-3027 OMB Control No: 0508-0002 Expiration Date: 09/30/2027
Updated 10-2025 TITLE VI AND ENVIRONMENTAL JUSTICE Title VI of the Civil Rights Act of 1964 requires federal agencies to ensure that programs or activities receiving federal funding, including those that affect human health or the environment, do not use discriminatory criteria, methods, or practices that adversely impact protected groups. USDA is advancing environmental justice by carrying out its responsibilities under the law to identify and address disproportionate and adverse public health and environmental, climate-related, and cumulative impacts on communities with environmental justice concerns. USDA invites the public to bring to its attention possible violations of our nation's environmental laws. Please use this form to let the USDA know of any environmental, health and climate impacts on individuals and communities that may be caused by the activities of USDA, its Mission Areas or agencies. Please understand that submitting this complaint form has no effect on any statute of limitations or other filing requirements that might apply to any complaint you may have. Further, by submitting this complaint you have not commenced a lawsuit or other legal proceeding, and this office has not initiated a lawsuit or proceeding on your behalf. NATIONAL ORIGIN DISCRIMINATION Discrimination based on national origin includes discrimination based on the country, world region, or place where a person or their ancestors come from; a person's limited English proficiency or English learner status; and a person's actual or perceived shared ancestry or ethnic characteristics, including membership in a religion that may be perceived to exhibit such characteristics (e.g., Hindu, Jewish, Muslim, and Sikh students). USDA ACCESSIBILITY STATEMENT Section 508 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794d) authorizes individuals to file administrative complaints and civil actions against the Department, limited to the Department’s alleged failure to procure accessible technology. The statute requires federal agencies to process Section 508 complaints according to the same complaint procedures used to process Section 504 complaints. USDA is committed to making its digital content accessible. USDA customers, employees, job applicants, and members of the public with disabilities must have access to information and communication technology (ICT) comparable to the access available to those without disabilities.
Any person alleging discrimination on the basis of race, age1 disability, color, sex or national origin must file a complaint, with the United States Secretary of Agriculture, within 180 days of the alleged discriminatory action.
Where to file a complaint: WIC STATE & FEDERAL DISCRIMINATION COMPLAINT AGENCIES
An individual has the right to file his or her complaint of discrimination with any or all of the relevant agencies listed below. The individual can also simultaneously avail himself or herself of this Department of Public Health’s Discrimination Complaint Procedure.
1. The Connecticut Commission on Human Rights & Opportunities Complaints should be filed with the Commission on Human Rights and Opportunities no later than one hundred and eighty (180) days after the alleged act of discrimination occurred.
Capitol Regional Office 450 Columbus Boulevard Hartford, CT 06103-1835 Tel: (860) 566-7710 TDD (860) 566-7710 Southwest Region 350 Fairfield Avenue, 6th Floor Bridgeport, CT 06604 Tel: (203) 579-6246 TDD: (203) 579-6246 West Central Regional Office 55 West Main Street, Suite 210 Waterbury, CT 06702 Tel: (203) 805-6530 TDD: (203) 805-6579 Eastern Regional Office 100 Broadway Norwich, CT 06360 Tel: (860) 886-5703 TDD: (860) 886-5707 Administrative Headquarters 450 Columbus Boulevard Hartford, CT 06103-1835 Tel: (860) 541-3400 TDD: (860) 541-3459
2. CT District Office, United States Labor Department Wage and Hour Division 135 High Street Hartford, CT 06103 Tel: (860) 240-4277
3. United States Department of Agriculture (USDA) Mail the completed form to: Office of the Assistant Secretary for Civil Rights 1400 Independence Ave, SW, Stop 9410 Washington, D.C 20250-9410 Local area: (202) 260-1026. Toll free: (833)256-1665 Local/Federal relay: (800) 877-8339 Spanish relay: (800) 845-6136 Fax: 1-833-256-1665
AD-3027 N.º de control OMB: 0508-0002 Fecha de vencimiento: 09/30/2027 Departamento de Agricultura de Estados Unidos Formulario de quejas por discriminación en los programas del USDA
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Información del demandante Nombre Inicial del segundo nombre Apellido Dirección postal (incluya la ciudad, el estado y el código postal completos) Teléfono principal Teléfono alternativo Correo electrónico La mejor manera para comunicarnos con usted: Correo Teléfono Correo electrónico □ Otro Si tiene dificultades para entender el inglés, puede solicitar servicios de asistencia con el idioma llamando al 866-632-9992. Habrá ayuda disponible a las personas que no dominen el inglés. Las personas con discapacidad que necesiten medios alternativos de comunicación (por ejemplo, braille, letra grande, lenguaje de señas americano) deben comunicarse con la agencia estatal o local responsable que administre el programa o comunicarse con el Departamento de Agricultura de los Estados Unidos (USDA) mediante el Servicio Federal de Retransmisión de Telecomunicaciones llamando al 711 (voz TTY). Información sobre representantes ¿Tiene un representante? Sí No ¿Tiene autorización por escrito de un representante? Si la respuesta es sí, adjúntela. Sí No Primer nombre Apellido Dirección postal (incluya la ciudad, el estado y el código postal completos) Teléfono Correo electrónico Información sobre la queja (adjunte páginas adicionales y documentación de apoyo si es necesario) 1. Escriba el nombre del programa que solicitó (si lo conoce/corresponde). 2. Seleccione la agencia del USDA que dirige el programa o que ofrece ayuda económica federal para dicho programa. Servicio de Marketing Agrícola (Agricultural Marketing Service, AMS) Servicio Agrícola Exterior, FAS/Comercio y Asuntos Agrícolas Exteriores, TFAA (Foreign Agricultural Service, FAS/Trade and Foreign Agricultural Affairs, TFAA) Servicio de Alimentación y Nutrición, (Food and Nutrition Service, FNS) Servicio Forestal (Forest Service, FS) Agencia de Servicios Agrícolas (Farm Service Agency, FSA) Instituto Nacional de Alimentación y Agricultura (National Institute of Food and Agriculture, NIFA) Servicio de Conservación de Recursos Naturales (Natural Resources Conservation Service, NRCS) Desarrollo Rural (Rural Development, RD) Otro Se desconoce 3. Fecha de la presunta discriminación reciente (mm/dd/aaaa) 4. Lugar o dirección de la oficina donde ocurrió la discriminación 5. ¿Quién cree que lo discriminó? Incluya los nombres de las personas implicadas en la presunta discriminación (si los conoce).
AD-3027 N.º de control OMB: 0508-0002 Fecha de vencimiento: 09/30/2027 Departamento de Agricultura de Estados Unidos Formulario de quejas por discriminación en los programas del USDA
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6. ¿Qué le ocurrió? (incluya las fechas de cada acusación) 7. Es una infracción de la ley discriminarlo basado en lo siguiente: raza, color, país de origen, religión, sexo, orientación sexual, discapacidad, edad, estado civil, situación familiar/paternal, ingresos derivados de un programa de asistencia pública y creencias políticas. (No todas las bases se aplican a todos los programas). Se prohíben las represalias basadas en actividades anteriores relacionadas con los derechos civiles. Creo que se me discriminó sobre la base de:
Raza Sexo Estado civil Color Discapacidad Situación familiar/parental País de origen Edad Ingresos de asistencia pública Creencias políticas Religión ☐ Represalias (actividad anterior en defensa de los derechos civiles) Soluciones legales 8. ¿Cómo le gustaría que se resolviera esta queja? 9. ¿Ha presentado alguna queja sobre los incidentes ante otra agencia federal, estatal o local o ante un tribunal? 10. Si respondió Sí, ¿ante qué agencia o tribunal presentó su queja? 11. Si respondió Sí, ¿cuándo presentó su queja? (mm/dd/aaaa)
Firma del demandante Fecha Firma del representante Fecha
N.º de control OMB: 0508-0002 Fecha de vencimiento: 09/30/2027
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INSTRUCCIONES PROPÓSITO: El Formulario de quejas por discriminación en los programas 3027 (AD 3027) del Departamento de Agricultura puede usarse si cree que ha sufrido discriminación en cualquier programa o actividad del USDA y quiere presentar una queja por discriminación. Puede usar el formulario para presentar una queja por discriminación basada en raza, color, país de origen (incluyendo poco dominio del inglés), religión, sexo, orientación sexual, discapacidad, edad, estado civil, situación familiar/parental, ingresos derivados de un programa de asistencia pública y creencias políticas. También puede usar este formulario para presentar una queja si algún programa o actividad del USDA, las áreas de su misión o sus agencias ha tenido un efecto ambiental perjudicial en su salud o en el entorno de un grupo protegido. No es necesario que use este formulario para presentar una queja por discriminación; puede enviar una carta o un correo electrónico en lugar de este formulario. La carta o el correo electrónico deben incluir la información solicitada en los puntos 1-11 de este formulario. Si decide usar este formulario, escriba a máquina o en letra de molde toda la información de los puntos 1-11 de este formulario y use más páginas si necesita más espacio. Si necesita ayuda para completar el formulario, llame al 866-632-9992.
Según el Título 7 del CFR 16.4(d), los beneficiarios y posibles beneficiarios de programas respaldados por ayuda económica indirecta del USDA pueden presentar quejas por escrito ante el USDA en las que se indican infracciones de las protecciones de libertad religiosa de la norma poniéndose en contacto con la Subsecretaría de Derechos Civiles (Office of the Assistant Secretary for Civil Rights, OASCR) del USDA o presentando una queja por escrito ante ella. Si necesita ayuda para completar este formulario (incluyendo servicios de traducción), puede llamar al (866) 632-9992. La ayuda estará disponible en inglés y para personas que no dominen el inglés u otros idiomas. Las personas con discapacidad que necesiten medios alternativos de comunicación para obtener información sobre el programa (por ejemplo, Braille, letra grande, lenguaje de señas americano) deben comunicarse con la agencia estatal o local responsable que administre el programa o comunicarse con el USDA mediante el Servicio de Retransmisión de Telecomunicaciones llamando al 711 (voz y TTY). Debemos tener una copia firmada de su queja. Si presenta un formulario o una carta incompletos o sin firmar, retrasará el procesamiento de su queja. PLAZO DE PRESENTACIÓN: Las quejas por discriminación en los programas deben presentarse dentro de los 180 días a partir de la fecha en que supo o debería haber sabido de la presunta discriminación, a menos que el USDA extienda el plazo. Las quejas enviadas por correo se consideran presentadas en la fecha en que el USDA las recibe. La documentación de la queja o los formularios de quejas enviados por correo electrónico se considerarán presentados en la fecha en que se reciba la queja. Las quejas presentadas después del plazo de 180 días deben incluir una explicación de una “buena causa” para el retraso. Por ejemplo, si:
1. No era razonablemente esperable que usted supiera del acto discriminatorio en el período de 180 días: 2. estaba gravemente enfermo o incapacitado; o 3. la misma queja se presentó ante otra agencia federal, estatal o local y esa agencia no hizo nada al respecto. POLÍTICA DEL USDA: La ley y la política federales prohíben la discriminación por motivos de raza, color y país de origen, incluyendo la discriminación por motivos de ascendencia compartida o características étnicas o por la ciudadanía de un país con una religión dominante. La discriminación basada en raza, color y país de origen también incluye la discriminación, incluyendo el acoso debido a que usted u otra persona sean, por ejemplo, judíos, musulmanes, árabes, hindúes o sijs; o basada en otras características étnicas y religiosas. Por ejemplo, personas que han sido objeto de insultos étnicos (como acoso antisemita o antimusulmán); acosadas por su apariencia, vestimenta o forma de hablar en relación con su origen étnico (como el color de la piel, vestimenta religiosa o el idioma que hablan); o estereotipadas basado en sus características étnicas percibidas. El USDA determinará si tiene jurisdicción según la ley para procesar la queja sobre la base identificada en la queja y en los programas indicados en la queja. Se prohíben las represalias basadas en actividades anteriores relacionadas con los derechos civiles.
N.º de control OMB: 0508-0002 Fecha de vencimiento: 09/30/2027
Updated 10-2025
DÓNDE PRESENTAR SU QUEJA: Puede enviar su formulario completo o carta al USDA por: Correo: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence, Ave, SW, Mail Stop 9410, Washington, DC 20250-9410. Correo electrónico: program.intake@usda.gov.
Para obtener más información, visite: https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complaint. INFORMACIÓN LEGAL CONSENTIMIENTO: Este Formulario de quejas por discriminación en los programas del USDA se entrega de conformidad con la Ley de Privacidad de 1974 (5 U.S.C. § 552a) y se usa para pedir información para procesar quejas por discriminación. El USDA solicita esta información según la Parte 15 del Título 7 del CFR. Si el formulario completado se acepta como queja, la información recopilada durante la investigación se usará para procesar su queja por discriminación en los programas. PROHIBICIÓN DE REPRESALIAS: Ninguna agencia, representante, empleado o agente del USDA, incluyendo personas que representan al USDA y sus programas, intimidará, amenazará, acosará, coaccionará, discriminará ni tomará ningún tipo de represalia contra una persona que haya presentado una queja por presunta discriminación o que participe de alguna manera en una investigación u otro procedimiento que plantee reclamos por discriminación. DECLARACIÓN DE LA LEY DE PRIVACIDAD (5 U.S.C. § 552a) AUTORIDADES: La recopilación de esta información está autorizada por el Título VI de la Ley de Derechos Civiles de 1964. (42 U.S.C. § 2000d); y las Secciones 504 y 508 de la Ley de Rehabilitación (Rehabilitation Act) de 1973 (29 U.S.C. §§ 794; 794d) y cualquier otra ley, norma y reglamentación contra la discriminación. PROPÓSITO: La información solicitada en este formulario se usa para procesar quejas por discriminación de conformidad con los estatutos señalados en la sección “Autoridades” de este aviso. Toda la información obtenida de este formulario quedará guardada en nuestro sistema de registro. USOS HABITUALES: Se puede encontrar más información de los usos habituales del sistema en el Aviso del sistema de registros USDA-2021-0007. Los registros mantenidos por OASCR se pueden ver en Internet en https://www.usda.gov/home/privacy-policy/system-records-notices. REVELACIÓN: La entrega de esta información es voluntaria. No completar este formulario puede causar retrasos en el procesamiento de la queja o que la queja sea rechazada por falta de información adecuada para continuar con el procesamiento. DECLARACIÓN DE LA LEY DE REDUCCIÓN DEL PAPELEO La Ley de Reducción del Papeleo de 1995 (Paperwork Reduction Act of 1995) (44 U.S.C. 3501 y siguientes) nos exige que lo informemos que estamos recopilando esta información para garantizar que su queja contenga toda la información necesaria para procesarla adecuadamente. OASCR usará la información para procesar su queja por discriminación. La respuesta a esta solicitud es voluntaria. La información que se entregue en este formulario solo se compartirá con personas que oficialmente deban conocerla y estará protegida de su revelación pública según las disposiciones de la Ley de Privacidad (5 U.S.C. § 552a(b)). El tiempo estimado que necesita para completar este formulario es de 60 minutos. Puede enviar comentarios sobre la precisión de este cálculo y cualquier sugerencia para completar el formulario en menos tiempo al U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Mail Stop 9410, DC 20250-9410. Ninguna agencia puede hacer ni patrocinar, y ninguna persona está obligada a responder, una recopilación de información que no muestre un número de control OMB válido y vigente. El número de control OMB de este formulario es 0508-0002.
N.º de control OMB: 0508-0002 Fecha de vencimiento: 09/30/2027
Updated 10-2025
TÍTULO VI El Título VI de la Ley de derechos civiles de 1964 exige que las agencias federales se aseguren de que los programas o actividades que reciben financiamiento federal, incluyendo aquellos que afectan la salud humana o el medio ambiente, no usen criterios, métodos o prácticas discriminatorias que perjudiquen a grupos protegidos. El USDA está promoviendo la justicia cumpliendo sus responsabilidades según la ley para identificar y tratar los efectos públicos y acumulativos desproporcionados y adversos en las comunidades con preocupaciones. El USDA invita al público a reportar posibles infracciones de las leyes ambientales de nuestra nación. Entienda que presentar este formulario de queja no tiene efecto alguno sobre ningún plazo de prescripción u otros requisitos de presentación que puedan aplicarse a cualquier queja que usted pueda tener. Además, presentando esta queja, usted no ha iniciado una demanda legal u otro procedimiento legal, y esta oficina no ha iniciado una demanda legal o procedimiento en su nombre. DISCRIMINACIÓN POR PAÍS DE ORIGEN La discriminación por el país de origen incluye la discriminación debido al país, la región del mundo o el lugar de donde proviene una persona o sus antepasados; el dominio limitado del inglés de una persona o su condición de estudiante de inglés; y la ascendencia compartida real o percibida de una persona o sus características étnicas, incluyendo la pertenencia a una religión que pueda percibirse como demostrativa de dichas características (por ejemplo, estudiantes hindúes, judíos, musulmanes y sijs). DECLARACIÓN DE ACCESIBILIDAD DEL USDA La Sección 508 de la Ley de Rehabilitación de 1973, con sus respectivas modificaciones (29 U.S.C. 794d), autoriza a las personas a presentar quejas administrativas y acciones civiles contra el Departamento, limitadas al presunto incumplimiento de adquirir tecnología accesible del Departamento. El estatuto exige que las agencias federales procesen las quejas de la Sección 508 de acuerdo con los mismos procedimientos de queja usados para procesar las quejas de la Sección 504. El USDA está comprometido a hacer que su contenido digital sea accesible. Los clientes, empleados, solicitantes de empleo y miembros del público con discapacidades que acuden al USDA deben tener acceso a tecnología de información y comunicación (ICT) comparable al acceso disponible para las personas sin discapacidades.
