Return to Equal Opportunity-Policy

I.    Policy. This procedure establishes the department's Methods of Administration to ensure nondiscrimination and equal opportunity in service delivery in accordance with state and federal laws.

A.    The policies prescribed in this procedure apply to all department sponsored programs and activities involved in providing equally effective and equally accessible quality services to Department of Health clients and potential clients.

1.    No person shall on the basis of age, color, disability, national origin, race, religion or sex be excluded from participation in, be denied benefits of, or be subjected to unlawful discrimination under any program or activity receiving or benefiting from federal financial assistance and administered by the department.

2.    No person shall be retaliated against, harassed, intimidated, threatened, coerced or discriminated against for making a charge, testifying, assisting or participating in any manner in an investigation, proceeding or hearing, or for opposing alleged unlawful discriminatory practices prohibited by this policy or related to state and federal laws, rules and regulations.

B.    Department of Health programs and contracted service providers providing aids, benefits or services to Department of Health clients or potential clients may not on the basis of age, color, disability, national origin, race, religion or sex (except as provided by federal law):

1.    Deny any individual the opportunity to participate in or receive the aid, benefit or service provided.

2.    Provide any individual any service, financial aid or other benefit that is different or is provided in a different manner from that provided to others.

3.    Afford or provide an individual an opportunity to participate in or receive aid, benefit or service that is not equal to that afforded or provided to others.

4.    Subject an individual to segregated, different or separate treatment in any manner related to receipt of aid, benefit or service unless such action is necessary to provide qualified persons with disabilities with aid, benefits or services that are as effective as those provided to others.

5.    Treat an individual differently from others in determining admission, enrollment, quota, eligibility, membership or other requirement or condition which must be met in order to receive any aid, benefit or service provided. (The exclusion of persons from the benefits of a program limited by federal statute or executive order to a specific class of persons is not prohibited.)

6.    Deny any individual the opportunity to participate as a member of a planning or advisory board.

A.    Code of Federal Regulations, in order by chapter.

1.    7 CFR, Part 15, requires nondiscrimination on the basis of age, color, disability, national origin, race, religion or sex in programs and activities funded by the United States Department of Agriculture.

2.    28 CFR, Part 35, provides for nondiscrimination on the basis of disability in state and local government services and implements Title II of the Americans with Disabilities Act of 1990.

3.    29 CFR, Part 1630, equal employment opportunity for individuals with disabilities, prohibits discrimination against qualified individuals with disabilities in all aspects of employment and implements Title I of the Americans with Disabilities Act of 1990.

4.    41 CFR, Chapter 60, Office of Federal Contract Compliance Program, Equal Employment Opportunity, prohibits employment discrimination on the basis of race, color, religion, sex, national origin, disability and Vietnam era veterans status; and requires the development of an affirmative action plan to promote affirmative action in the employment and advancement of qualified women, Vietnam era veterans, minorities and individuals with disabilities in covered government contracts and subcontracts. (Executive Orders 11246, 11375, 11701 and 11758)

5.    45 CFR, Part 80, requires nondiscrimination on the basis of race, color or national origin in federally assisted programs and activities. (Title VI of the Civil Rights Act of 1964, as amended, 42 United States Code 2000d et sec.)

6.    45 CFR, Part 84, requires nondiscrimination on the basis of disability in federally assisted programs and activities. (Section 504, Title V of the Rehabilitation Act of 1973, as amended, 29 USC 794)

7.    45 CFR, Part 86, requires nondiscrimination on the basis of sex under federally assisted education programs and activities. (Title IX of the Education Amendments of 1972, as amended, 230 USC 1681 et seq.)

8.    45 CFR, Part 91, requires nondiscrimination on the basis of age in federally assisted activities. (Age Discrimination Act of 1975, 42 USC 6101 et seq.)

B.    Florida Statutes, in order by statute number.

1.    Section 110.105, Florida Statutes, establishes the nondiscriminatory employment policy of the state of Florida.

2.    Section 110.201(3), Florida Statutes, requires each state agency to comply with all federal regulations necessary to receive federal funds.

C.    Florida Administrative Code.

1.    Chapter 60L-21, Florida Administrative Code, provides for equal employment opportunity and affirmative action, requiring each state agency to develop and implement its affirmative action program, assuring equal employment opportunity.

III.    Supportive Data. Not Applicable.

IV.    Signature Line with Effective Date.

V.    Definitions.

A.    Accessibility.

1.    Architectural. A barrier-free environment in which the mobility of persons with disabilities is not inhibited by external forces such as architectural design.

2.    Program. The operations of each program or activity (delivery of client services) so that the program or activity, when viewed in its entirety, is readily accessible to persons with disabilities. This does not require that each facility or every part of a facility be made accessible to and usable by persons with disabilities. Providers with fewer than 15 employees may, as an alternative, refer the clients with disabilities to other providers of those services that are accessible.

B.    Accommodation to Persons with Disabilities. The obligation of an organization doing business with the government to make reasonable accommodations to an applicant’s or employee’s physical and mental limitations. It may mean changing a job slightly, doing it in a different order, modifying equipment, moving supplies nearer a work site, etc. Exception: If the accommodation clearly affects the safety and efficiency of the organization or substantially affects costs, the accommodation is not required.

C.    Adverse Impact. Applying uniformly to all applicants or employees certain human resource or admission policies (e.g., word-of-mouth recruiting, diploma requirements, intelligence tests, minimum height requirements) that have the effect of denying benefits, services, employment or advancement to members of affected classes. Business necessity is the only justifiable reason for adverse impact.

D.    Affected Class (Protected). Any group or member of that group protected by the nondiscrimination laws or the affirmative action obligations of federal contractors. The federal nondiscrimination laws protect individuals from discrimination because of age, color, disability, national origin, race, religion and sex.

E.    Artificial (Arbitrary or Unnecessary) Barriers to Employment. These are non-job-related requirements for employment that prevent minorities, women and individuals with disabilities from being hired or promoted. Such barriers may be found in recruitment, selection, placement, testing, transfers, promotion, seniority, lines of progression or other terms and conditions of employment. Typical artificial barriers to employment that have been found illegal are height requirements, requirements for high school diplomas which have no real relation to the skills required by any job, language requirements for jobs which require limited verbal communication.

F.    Civil Rights Act of 1964. A comprehensive law establishing federal guarantees of civil rights in the fields of voting, public accommodations, use of public facilities, public education, benefits under federally assisted programs, employment and other fields generally categorized as equal protection of the laws within the meaning of the Fourteenth Amendment to the United States Constitution. Title VII of the Civil Rights Act of 1964, as amended by the Equal Employment Opportunity Act of 1972, prohibits discrimination in public employment on the basis of race, color, religion, sex or national origin. Title VI prohibits discrimination under any program or activity receiving Federal financial assistance on the basis of race, color or national origin.

G.    Complainant or Charging Party. A person who files a complaint of discrimination as provided in section VII of this procedure.

H.    Department Program and Activities. The operating units of the department include, but are not limited to, the program office, children’s medical services (CMS) units, labs, county health department units, as well as other service and treatment facilities.

I.    Discrimination (Unlawful). The failure to treat persons equally because of their race, sex, age, religion, national origin or disability.

J.    Disparate Treatment. Enforcing rules, regulations or other policies or practices differently for different groups. This kind of uneven treatment is a violation of Titles VI and VII. Example: A supervisor who ignores applicant requirements for white males, allowing many to qualify, then applies the same requirements rigidly for blacks or women so that few blacks or women qualify. Uneven enforcement of work, attendance, punctuality, safety or other rules are also examples of disparate treatment, all of which violate Titles VI and VII.

K.    Equal Employment Opportunity (EEO) Contact. Appointed by a county health department (CHD) or children’s medical services (CMS) unit and responsible for assisting the EEO coordinators or the Office of Equal Opportunity and Minority Health in the overall coordination of EEO activities.

L.    EEO Coordinators. Appointed by a county health department or consortium and responsible for the overall coordination of EEO activities.

M.    EEO Liaisons. Appointed by division directors and responsible within their division for overall coordination of EEO activities.

N.    Federal Financial Assistance includes;

1.    grants and loans of federal funds,

2.    the grant or donation of federal property and interests in property,

3.    the detail of federal personnel,

4.    the sale and lease of, and the permission to use federal property or any interest in such property without consideration or at a nominal consideration, or at a consideration which is reduced for the purpose of assisting the recipient, or in recognition of the public interest to be served by such sale or lease to the recipient, and

5.    any federal agreement, arrangement, or other contract which has as one of its purposes the provision of assistance.

O.    Federal Government Contract. Any agreement or modification thereof between any contracting agency (federal) and any person (contractor or subcontractor) for use of real or personal property including lease arrangements. The term "service" as used in this paragraph includes, but is not limited to, the following services: utility construction, research, transportation, insurance and fund depository, irrespective of whether the government is the purchaser or seller. The term "federal government contract" does not include agreements in which the parties stand in relationship of employer and employee, and federally assisted contracts. (Unless specified, Department of Health contracts and grants are considered federal financial assistance and not government contracts.)

P.    Hearing Impaired Person. A deaf or hard of hearing person defined as follows:

1.    Deaf Person. An individual who has suffered a permanent hearing impairment and is not able to discriminate speech sounds in verbal communication, with or without amplification devices.

2.    Hard of Hearing Person. An individual who has suffered a permanent hearing impairment which is severe enough to necessitate the use of amplification devices to discriminate speech sounds in verbal communication.

Q.    HHS Office of Civil Rights. The Office of Civil Rights of the Department of Health and Human Services, responsible for Department of Health compliance with Americans with Disabilities Act of 1990, Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975 and the Omnibus Budget Reconciliation Action of 1981.

R.    Individual with a Disability. Any person who has a physical or mental impairment that substantially limits one or more major life activity, has a record of such an impairment, or is regarded by a recipient of federal financial assistance as having such an impairment.

1.    Physical or Mental Impairment. Any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the body systems, i.e., neurological, musculoskeletal, special sense organs, respiratory (including speech) organs, cardiovascular, reproductive or digestive, genitourinary, hemic and lymphatic, skin and endocrine. Any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness and specific learning disabilities.

2.    Major Life Activities. Those functions, such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working.

3.    Record of Impairment. A history of or being classified as having a mental or physical impairment that substantially limits one or more major life activities.

4.    Regarded as Having an Impairment. Having a physical or mental impairment that does not substantially limit major life activities, but such impairment is treated by a recipient as constituting such a limitation; having a physical or mental impairment that substantially limits major life activities only as a result of the attitudes of others toward such an impairment; or having none of these impairments, but being treated as having such an impairment.

S.    Program. Includes any program, project or activity for the provision of services, financial aid, or other benefits to, or for the provision of facilities for furnishing services, financial aid, or other benefits to individuals.

T.    Provider/Contractor. Any individual, organization, institution, or agency from which the department purchases or arranges for the provision of client services or benefits under departmental programs and activities.

U.    Public Entity. Any public entity covered by Title II of the Americans with Disabilities is defined as;

1.    any state or local government;

2.    any department, agency, special purpose district, or other instrumentality of a state or local government; or

3.    certain commuter authorities as well as AMTRAK.

V.    Race/Ethnic Categories. For record keeping purposes of this plan, each applicant and employee is classified in only one of the following race/ethnic categories:

1.    Black, not of Hispanic origin.

2.    White, not of Hispanic origin.

3.    Hispanic.

4.    American Indian or Alaskan Native.

5.    Asian or Pacific Islanders.

W.     Section 504. Title V, Section 504 of the Rehabilitation Act of 1973, which establishes federal law requiring nondiscrimination on the basis of disability in federally assisted programs and activities.

X.    Title VI. Title VI of the Civil Rights Act of 1964 prohibits discrimination on the basis of race, color, or national origin in any program or activity receiving federal financial assistance.

VI.    Protocol.

A.    Responsibilities

1.    Responsibilities Under Title VI.

a.    Title VI of the Civil Rights Act of 1964 as implemented by 45 CFR Part 80 prohibits discrimination on the basis of race, color or national origin in any program or activity receiving or benefiting from federal financial assistance. Specifically, Title VI states, "no person in the United States shall; on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any program or activity receiving Federal financial assistance from the Department of Health and Human Services."

b.    Within the Department of Health, the Secretary or his designee is responsible for coordinating the department’s efforts to comply with Title VI. Such responsibility includes coordination of the development and uniform implementation of the federally required "Methods of Administration" to ensure the delivery of equally effective and equally accessible services in a nondiscriminatory manner. County health department administrators and other departmental entities have designated persons as Title VI coordinators to coordinate the agency’s efforts to comply with Title VI.

c.    Contracted service providers with 15 or more employees are required to designate Title VI coordinators to coordinate their efforts to comply with Title VI to provide reasonable assurances that all services are equally effective, equally accessible and provided in a nondiscriminatory manner.

d.    The Department of Health has submitted written assurance to the United States Department of Health and Human Services that the Department of Health will comply with the federal regulation implementing Title VI. The Department of Health must secure written assurance from each of its providers, providing services to clients, that the provider will also comply with this federal regulation which specifies that the Department of Health and its providers may not directly or through contractual or other arrangements:

(1)    Deny an individual any service, financial aid, or other benefit provided based on race, color or national origin.

(2)    Provide any service, financial aid, or other benefit to an individual that is different, or is provided in a different manner, from that provided to others.

(3)    Subject an individual to segregation or separate treatment based on race, color or national origin.

(4)    Restrict an individual, because of race, color or national origin, in any way in the enjoyment of any advantage or privilege enjoyed by others receiving any service, financial aid, or other benefit.

(5)    Treat an individual differently from others in determining whether he or she satisfies any admission, enrollment, quota, eligibility, membership or other requirement or condition because of race, color or national origin.

(6)    Deny on the basis of race, color or national origin, an opportunity for an individual to participate in any program.

(7)    Deny an individual the opportunity to participate as a member of a planning or advisory board because of the individual’s race, color or national origin.

(8)    Utilize criteria or methods of administration which have the effect of subjecting individuals to discrimination because of their race, color or national origin, or have the effect of defeating or substantially impairing accomplishment of the objectives of the program.

(9)    Select a site or location of a facility with the effect of excluding individuals from, denying them benefits of, or subjecting them to discrimination under any program or activity on the basis of race, color or national origin.

Note: An individual shall not be deemed to be subject to discrimination by reason of his exclusion from the benefits of a program limited by federal law to individuals of a particular race, color, or national origin.

e.    Departmental entities or contracted service providers, providing services to clients, will submit compliance reports annually and as otherwise requested, to the designated Department of Health official to enable the department to carry out its obligations under compliance reporting requirements. Even in the absence of prior discrimination, departmental entities or contracted service providers may take affirmative action to overcome the effects of conditions limiting participation by individuals of a particular race, color or national origin.

2.    Responsibilities Under Section 504.

a.    Section 504 of the Rehabilitation Act of 1973 is designed to eliminate discrimination on the basis of disability in any program or activity receiving federal financial assistance. 45CFR§84.4 (a) states in part: "No qualified individual with a disability shall, on the basis of disability, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity which receives or benefits from federal financial assistance."

b.    Within the Department of Health, the Secretary or his designee is responsible for coordinating the department’s efforts to comply with Section 504. County health department directors and other departmental entities have designated persons as Section 504 coordinators to coordinate agency efforts to comply with Section 504, including development and implementation of county specific auxiliary aids plans. This plan should be submitted to the Office of Equal Opportunity and Minority Health by March 31 of each year.

c.    Contracted service providers with 15 or more employees are required to designate Section 504 coordinators to coordinate their efforts to comply with Section 504, including the development and implementation of an auxiliary aids plan.

d.    As defined by the federal regulation implementing Section 504, "Individual with a disability" means any person who has a physical or mental impairment that substantially limits one or more major life activities, has a record of such impairment, or is regarded as having such impairment. A "qualified individual with a disability" includes a person who meets the essential eligibility requirements for receipt of activities or services. The Department of Health and its providers may not, directly or through contractual or other arrangements:

(1)    Deny a qualified individual with a disability any service, or the opportunity to participate in or benefit from any service, because of that person’s disability.

(2)    Afford a qualified individual with a disability an opportunity not equal to that opportunity afforded others to receive or benefit from services.

(3)    Provide a qualified individual with a disability with services that are not equally effective to the services provided to others. (Note: To be equally effective, the services are not required to produce identical results or levels of achievement for persons with a disability and persons without a disability, but must afford persons with a disability equal opportunity to obtain the same results, to gain the same benefit, or to reach the same level of achievement in the most integrated setting appropriate to each individual’s needs.)

(4)    Provide services that are separate or different from those services provided to others unless such action is necessary to provide qualified individuals with a disability or to any class of individuals with a disability with aid, benefits or services that are as effective as those provided to others.

(5)    Aid or perpetuate discrimination against a qualified individual with a disability by providing significant assistance to an agency, organization, or person that discriminated based on handicap in providing any aid, benefit or service to beneficiaries of their programs.

(6)    Deny the opportunity to participate as a member of planning or advisory boards to individuals with disabilities.

(7)    Limit an individual with a disability in the enjoyment of any right, privilege, advantage or opportunity enjoyed by others receiving an aid, benefit or service.

(8)    Deny an individual with the opportunity to participate in programs or activities that are not separate or different, even if a separate or different program or activity exists to accommodate individuals with disabilities.

(9)    Utilize criteria or methods of administration that subjects a person to discrimination on the basis of disability, defeats or substantially impairs accomplishment of the objectives of the program with respect to individuals with a disability, perpetuates the discrimination of another recipient if both recipients are subject to common administrative control or are agencies of the same state.

(10)    Select sites or locations for facilities that have the effect of excluding persons with a disability from, denying them the benefits of, or subjecting them to discrimination under any program or activity on the basis of their disability or that defeats or substantially impairs the accomplishment of the objectives of the program or activity.

e.    The exclusion of a individual from a program limited by federal law to persons with disabilities or the exclusion of a specific class of individuals with disabilities from a program limited by law to a different class of individuals with a disability is not prohibited.

f.    The department and its providers of client services must operate programs so that each program, when viewed in its entirety, is readily accessible to persons with disabilities. The department and its providers may comply with this requirement through such means as redesigning equipment, reassigning aides to beneficiaries, delivering services at alternate accessible sites or through home visit, altering existing facilities, constructing new facilities, making all programs and services accessible by telecommunication devices for the deaf, providing interpreters for the deaf, supplying Braille or taped materials for persons with impaired vision or other similar means.

g.    The department and its providers of client services are not required to make each existing facility or every part of a facility accessible to and usable by persons with a disability; nor are they required to make structural changes in existing facilities where other methods are effective in achieving compliance. However, in choosing among available methods, the department and its providers must give priority to those methods that offer programs to persons with disabilities in the most integrated setting appropriate.

h.    If a service provider with fewer than 15 employees, after consultation with a person with a disability seeking its services, determines that there is no method of complying with the program accessibility requirements other than making significant alteration in its existing facilities, the provider may refer the individual with a disability to another provider whose services are accessible.

i.    The department and its client contracted service providers with 15 or more employees are required to provide appropriate auxiliary aids to qualified persons with impaired sensory, manual or speaking skills when such aids are necessary to afford those persons an equal opportunity to benefit from any service offered by the department or its providers. Auxiliary aids may include Braille or taped material, interpreters for the deaf and other aids for persons with impaired hearing, vision or mobility. Providers with fewer than 15 employees are required to provide auxiliary aids when the provision of such aids does not significantly impair the ability of the provider to provide its benefits or services.

j.    The department and its providers of services to infants in programs or activities receiving federal financial assistance shall post an informational notice in locations where nurses and other medical professions providing health care and related services to infants will see it. This notice must state that nourishment and medically beneficial treatment (as determined with respect for reasonable medical judgments) should not be withheld from disabled infants solely on the basis of their present or anticipated mental or physical impairments. (Refer to 45CFR §84.55 for the specific requirements for this notice.)

k.    The department and its health care providers are required to report to the state child protective services agency, in a timely manner, circumstances which they determine to constitute known or suspected instances of unlawful medical neglect of infants with disabilities.

3.    Responsibilities Under the Americans with Disabilities Act.

a.    The Americans with Disabilities Act provides protection in several areas for individuals with disabilities and prohibits discrimination on the basis of disability.

b.    The Secretary or his designee is responsible for coordinating the department’s efforts to comply with and carry out its responsibilities under the Americans with Disabilities Act.

c.    The Americans with Disabilities Act requires that:

(1)    No qualified individual with a disability shall, on the basis of disability, be excluded from participation in or be denied the benefits of the services, programs, or activities of a public entity, or be subjected to discrimination by the department or its contracted service providers.

(2)    The department or its contracted service providers in providing any aid, benefit, or service may not on the basis of disability:

(a)    Deny a qualified individual with a disability the opportunity to participate in or benefit from the aid, benefit, or service;

(b)    Afford a qualified individual with a disability an opportunity to participate in or benefit from the aid, benefit, or service that is not equal to that afforded others;

(c)    Provide a qualified individual with a disability with an aid, benefit, or service that is not as effective in affording equal opportunity to obtain the same result, to gain the same benefit, or to reach the same level of achievement as that provided to others;

(d)    Provide different or separate aids, benefits, or services to individuals with disabilities or to any class of individuals with disabilities than is provided to others unless such action is necessary to provide qualified individuals with disabilities with aids, benefits, or services that are as effective as those provided to others;

(e)    Aid or perpetuate discrimination against a qualified individual with a disability by providing significant assistance to an agency, organization, or person that discriminates on the basis of disability in providing any aid, benefit, or service;

(f)    Deny a qualified individual with a disability the opportunity to participate as a member of planning or advisory boards;

(g)    Otherwise limit a qualified individual with a disability in the enjoyment of any right, privilege, advantage, or opportunity enjoyed by others receiving the aid, benefit, or service.

(3)    The department and its providers may not deny a qualified individual with a disability the opportunity to participate in services, programs, or activities that are not separate or different, despite the existence of permissibly separate or different programs or activities.

(4)    The department and its providers may not utilize criteria or methods of administration that:

(a)    Have the effect of subjecting qualified individuals with disabilities to discrimination on the basis of disability;

(b)    Have the purpose or effect of defeating or substantially impairing accomplishment of the objectives of the program by individuals with disabilities;

(c)    Perpetuate the discrimination of another public entity if both entities are subject to common administrative control or are agencies of the same state.

(5)    In the selection of a site or location of a facility, the department and its contracted service providers may not make a selection that:

(a)    Has the effect of excluding individuals with disabilities from, denying them the benefit of, or otherwise subjecting them to discrimination.

(b)    Has the purpose or effect of defeating or substantially impairing the accomplishment of the objectives of the service, program or activity.

(6)    In the selection of procurement contractors, the department may not subject qualified individuals with disabilities to discrimination based on disability.

(7)    The department will not administer a licensing or certification program in a manner that subjects qualified individuals with disabilities to discrimination on the basis of disability, nor establish requirements for the programs or activities of licensees or certified entities that subject qualified individuals with disabilities to discrimination on the basis of disability. The programs or activities of entities that are licensed or certified by the department are not covered by this part.

(8)    The department will make reasonable modifications in policies, practices, or procedures when the modifications are necessary to avoid discrimination on the basis of disability, unless the modifications would fundamentally alter the nature of the service, program, or activity.

(9)    The department will not impose or apply eligibility criteria that screens out or tends to screen out an individual with a disability or any class of individuals with disabilities from fully and equally enjoying any service, program or activity unless such criteria is necessary for the provision of the service, program or activity offered.

(10)    The department is not prohibited from providing benefits, services, or advantages to individuals with disabilities, or to a particular class of individuals with disabilities beyond those required by the Americans with Disabilities Act.

(11)    The department shall administer services, programs and activities in the most integrated setting appropriate to the needs of qualified individuals with disabilities.

(12)    The department shall not require an individual with a disability to accept an accommodation, aid, service, opportunity, or benefit provided under the Americans with Disabilities Act that the individual chooses not to accept.

(13)    The Americans with Disabilities Act does not authorize the representative or guardian of an individual with a disability to decline food, water, medical treatment, or medical services for that individual.

(14)    The department may not place a surcharge on a particular individual with a disability or any group of individuals with disabilities to cover the costs of measures, such as provision of auxiliary aids or program accessibility, that are required to provide that individual or group with the nondiscriminatory treatment required.

(15)    The department shall not exclude or otherwise deny equal services, programs, or activities to an individual or entity because of the known disability of an individual with whom the individual or entity is known to have a relationship or association.

(16)    The department shall not deny health services, or services provided in connection with current illegal use of drugs, if the individual is otherwise entitled to such services. However, a drug rehabilitation or treatment program may deny participation to individuals who engage in illegal use of drugs while they are in the program.

(17)    The department and its contracted service providers shall not discriminate against any individual because that individual has opposed any act or practice made unlawful by the Americans with Disabilities Act (ADA), or who made a charge, testified, assisted, or participated in any manner in an investigation, proceeding or hearing under the ADA.

(18)    The department and its contracted service providers shall not coerce, intimidate, threaten, or interfere with any individual in the exercise or enjoyment of, or on account of his or her having exercised or enjoyed, or on account of his or her having aided or encouraged any other individual in the exercise or enjoyment of, any right granted or protected by the ADA.

4.    Responsibilities Under the Age Discrimination Act.

a.    The Age Discrimination Act of 1975 prohibits discrimination on the basis of age in programs or activities receiving federal financial assistance. Each program and contracted service provider has primary responsibility to ensure that its programs and activities are in compliance with this act and to take steps to eliminate violations of this act.

b.    Within the Department of Health, the Secretary or his designee is responsible for coordinating the department’s efforts to comply with and carry out the department’s responsibilities under the Age Discrimination Act.

c.    The Age Discrimination Act requires that:

(1)    No person in the United States shall, on the basis of age, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under, any program or activity receiving federal financial assistance.

(2)    The department and its contracted service providers may not use age distinctions or take any other actions that have the effect of:

(a)    Excluding individuals from, denying them the benefits of, or subjecting them to discrimination under, a program or activity receiving federal financial assistance.

(b)    Denying or limiting individuals the opportunity to participate in any program or activity receiving federal financial assistance.

(3)    The department and its contracted service providers may take action based on age if the action reasonably takes into account age as a factor necessary to the normal operation or the achievement of any statutory objective of a program or activity. This includes circumstances when:

(a)    Age is used as a measure or approximation of one or more other characteristics; and

(b)    The other characteristic(s) must be measured or approximated in order for the normal operation of the program or activity to continue, or to achieve any statutory objective of the program or activity; and

(c)    The other characteristic(s) can be reasonably measured or approximated by the use of age; and

(d)    The other characteristic(s) are impractical to measure directly on an individual basis.

(4)    The department and its contracted service providers are permitted to take action otherwise prohibited, if that action is based on a factor other than age, even though that action may have a disproportionate effect on persons of different ages. An action may be based on a factor other than age if the factor bears a direct and substantial relationship to the normal operation of the program or activity or the achievement of a statutory objective.

(5)    The burden of proving age distinction or other action falls within the rule exceptions is on the department and its contracted service providers receiving Federal financial assistance.

(6)    If the department or its contracted service providers are operating a program that provides special benefits to the elderly or to children, the use of age distinctions shall be presumed to be necessary to the normal operation of the program.

B.    Assignment of Responsibilities within the Department of Health. Compliance with these procedures will be ensured individually and collectively by assignment of responsibilities for civil rights compliance activities as specified in this section.

1.    The Office of Equal Opportunity and Minority Health will be responsible for the coordination of all civil rights compliance activities and will:

a.    Provide technical assistance, guidance and necessary training to department personnel.

b.    Disseminate civil rights compliance information to the Equal Employment Opportunity (EEO) coordinators, other appropriate department personnel and interested parties.

c.    Process complaints of discrimination in accordance with procedures established by this section.

d.    Review compliance reports and investigations conducted by assigned state and county compliance representatives.

e.    Assist county and headquarters staff, as appropriate, with reviews of and correspondence to other agencies and service providers to achieve civil rights compliance.

f.    Inform department staff of pertinent civil rights issues and activities.

g.    Serve as liaison between the Department of Health and the United States Department of Health and Human Services’ Office for Civil Rights, and other agencies or groups concerned with the nondiscriminatory delivery of services.

h.    Conduct periodic on-site validation reviews of program, county and provider civil rights compliance activities to ensure uniform implementation of nondiscrimination requirements.

2.    Division directors will appoint employees as EEO liaisons to be responsible within their respective divisions for overall coordination of equal opportunity activities. The liaisons’ duties will include:

a.    Monitoring equal opportunity program or division functions within headquarters and coordinating county program monitoring through county EEO coordinators.

b.    Providing technical assistance to headquarters program offices regarding program accessibility.

c.    Investigating complaints of alleged discrimination.

d.    Coordinating preparation of required reports, including program or division specific portions of the affirmative action plan.

e.    Participating in and assisting EEO coordinators and Office of Equal Opportunity and Minority Health staff in equal opportunity and related civil rights compliance activities.

f.    Advising the respective division director of problems and recommended remedial action.

g.    Ensuring that the department’s policy statement, federal EEO posters and other related materials are displayed in appropriate areas for employees and the public.

3.    County health department directors, CMS and other unit directors, and the A. G. Holley Hospital administrator will be responsible for the implementation of Methods of Administration procedures and for ensuring compliance with all civil rights regulations and procedures effecting the departmental Methods of Administration. The Directors and the Administrator will appoint an EEO coordinator or contact person. The coordinators’ duties will include:

a.    Reviewing and monitoring for compliance with the civil rights regulations and procedures.

b.    Providing technical assistance as required and for providing the coordination of the Methods of Administration at the county or hospital level.

c.    Providing civil rights training or orientation as appropriate.

A.   Dissemination of Information. The Department of Health will provide notification of its compliance responsibilities to participants, potential participants, applicants, employees, providers and subcontractors. Further, the Department of Health will appropriately post its equal opportunity and nondiscrimination policy.

1.    Procedures for Notification.

a.    The Office of Equal Opportunity and Minority Health will distribute, as appropriate, copies of the Notice of Compliance/Statement of Policy to organizations in Florida representing minorities, women, senior citizens, and persons with disabilities.

b.    The Bureau of Human Resource Management will distribute, as appropriate, copies of the Notice of Compliance/Statement of Policy to those unions or associations having collective bargaining agreements with the department.

c.    The Notice of Compliance/Statement of Policy will be permanently posted as follows:

(1)    Offices of the deputy state health officers and deputy secretaries on official bulletin boards under their jurisdiction;

(2)    Headquarters’ division offices on official bulletin boards;

(3)    County, A. G. Holley Hospital, CMS and other departmental entity offices on official bulletin boards;

(4)    Servicing Human Resource Offices;

(5)    Service centers in client waiting rooms and client interviewing rooms at facilities serving clients;

(6)    Facilities of contracted service providers receiving or benefiting from Federal financial assistance administered by the Department of Health;

(7)    In a conspicuous place in all other department facilities or programs.

2.    Procedures for Monitoring Notification Requirements.

a.    The county, headquarters and departmental entity coordinators and contacts are responsible for periodic monitoring to ensure that notices are properly posted and that the department’s nondiscriminatory policy is appropriately disseminated.

b.    The respective county, headquarters, hospital contract or other administrative managers or supervisors, and EEO coordinators and contacts, as directed by the county health department directors, hospital administrator, or division directors, will conduct annual on-site reviews to determine department and provider compliance with this requirement.

3.    Supply of Posters.

a.    Notice of Compliance/Statement of Policy posters will be distributed by the Office of Equal Opportunity and Minority Health. Additional posters may be ordered from the forms warehouse.

B.    Civil Rights Compliance.

1.    The Department of Health assures that all employees, officials, agents, agencies, contractors, subcontractors, sub-grantees or others with whom it arranges to provide services or benefits to participants or employees in connection with any of the department’s programs and activities are not discriminating against those participants or employees in violation of applicable civil rights statutes, regulations, guidelines and standards. Each contract must include suitable language that assures compliance with civil rights laws.

2.    To provide reasonable assurances of compliance with civil rights laws, each service provider, departmental program, and institution will be reviewed annually by the designated manager for compliance.

a.    Each contract manager will maintain a list of current contracts and providers.

b.    The Civil Rights Compliance Checklist (Exhibit A) will be completed annually by all contracted service providers.

(1)    The checklist is subject to a desk review by the contract manager. The contract manager will submit the checklist to the EEO coordinator by June 15 of each year.

(2)    The EEO coordinator will report compliance reviews of service providers to the Office of Equal Opportunity and Minority Health by July 20 of each year on the Civil Rights Compliance Report (Exhibit B).

(3)    Each provider with 15 or more employees will be subjected to an on-site validation review once every three years. The On-Site Validation Review Report (Exhibit C) will be submitted to the EEO coordinator for final review and submission to the Office of Equal Opportunity and Minority Health.

(4)    For any provider found to be out of compliance, a corrective action plan will be developed or a compliance agreement will be negotiated to remedy any deficiencies found, or the contract will be terminated. The Office of Equal Opportunity and Minority Health must approve all corrective action plans.

c.    The Civil Rights Compliance Checklist will be completed annually by each county health department, hospital, local program and program office.

(1)    The checklist will be submitted to the EEO coordinator by June 15 of each year.

(2)    The EEO coordinator will report compliance reviews of local programs and program offices to the Office of Equal Opportunity and Minority Health by July 20 of each year on the Civil Rights Compliance Report.

(3)    The EEO coordinator and the Office of Equal Opportunity and Minority Health will complete the On-Site Validation Review Report for on-site civil rights reviews that are conducted.

(4)    The Office of Equal Opportunity and Minority Health will monitor compliance reviews through desk reviews of reports, validation reviews, on-site civil rights reviews corrective action plans, and the annual county specific affirmative action plans.

d.    Federal civil rights compliance reviews will be conducted as required by the federal agency involved. The Office of Equal Opportunity and Minority Health will act as the department liaison coordinating such reviews.

3.    Periodic on-site civil rights compliance reviews will be conducted to provide reasonable assurance of compliance with civil rights laws.

a.    Prior to conducting the on-site review, as well as, during the review:

(1)    Coordinate scheduling with the appropriate staff.

(2)    Obtain a brief description of the scope and nature of services provided.

(3)    Obtain and review a description of the organization and structure for the provision of these services, including size of staff, by types of positions, e.g., nurses, counselors, etc.

(4)    Obtain and review statistics, giving racial and ethnic breakdown showing:

(a)    Number of applicants in the preceding year.

(b)    Number of persons currently receiving assistance or services.

(c)    Any other statistics available by race, sex, and national origin, such as average monthly WIC assistance, infant and maternal mortality rate, number of referrals to other agencies or programs and client area demographics.

(5)    Review available information such as: facility brochures, pamphlets or questionnaires; completed Civil Rights Compliance Checklist; auxiliary aids and limited English proficiency plans; infectious disease control procedures; affirmative action plans; civil rights complaints and complaint procedures; special incident reports; management reviews; program monitoring reports; self-evaluations; and accessibility studies.

(6)    Review other relevant information that is available regarding comparative data such as the location and racial utilization of other similar facilities.

b.    During the facility on-site review:

(1)    Visit the facility or program and interview key staff, including designated Title VI and Section 504 coordinator(s) to discuss program, policies, and activities of each unit of operation.

(2)    Use the On-Site Validation Review Report and address all elements on the report.

c.    County, local office, or program office review:

(1)    Describe the methods used, including time intervals, by the program office to monitor civil rights requirements and to conduct reviews.

(2)    Identify any forms or instructions developed to supplement those provided by the Office of Equal Opportunity and Minority Health (attach copies, if indicated).

(3)    Describe methods used to assure continued compliance with nondiscrimination in services on the part of staff of the county or headquarters program.

(4)    Describe methods used to assure that staff make referrals to or otherwise utilize for beneficiaries only those vendors or community agencies offering services without discrimination and who provide equally effective and equally accessible quality services to those referred.

(5)    Describe how clients are assigned to staff.

(6)    Describe how trainees or employees are selected and assigned.

d.    Handling Complaints of Discrimination.

(1)    Identify methods used in disseminating information concerning the right to file a complaint to:

(a)    Beneficiaries of assistance or services.

(b)    Applicants or potential applicants.

(c)    Other interested persons and the general public.

(2)    Describe methods for receiving, handling, investigating and making final disposition of complaints.

(3)    Summarize the complaints of discrimination received during the reporting period, including the nature of discrimination alleged, findings, disposition of complaints and any corrective steps taken.

e.    Concluding the Review.

(1)    Deficiencies and accomplishments should be discussed with the appropriate manager and EEO coordinator.

(2)    Courses of corrective action and time elements involved should be discussed with the administrator and the EEO coordinator as appropriate.

(3)    A letter of findings of compliance or noncompliance should be sent to the facility with the report. Deficiencies, corrective action and time elements should be included, if applicable.

(4)    If the problem appears to be severe, a follow-up visit will be made to determine progress in the areas of noted deficiencies. Any recommendations for contract termination or referral for administrative or legal proceedings will be made to the county health department, CMS unit director or division director.

C.    Auxiliary Aids and Limited English Proficiency Plan. The department and its contracted providers of client services will provide appropriate auxiliary aids to individuals with impaired sensory, manual, or speaking skills where necessary to afford such persons an equal opportunity to benefit from programs and benefits of the department. Interpreters and auxiliary aids will be available for use by clients or potential clients with impaired sensory, manual or speaking skills in each phase of the service delivery process when the lack of such interpreters or aids may in effect deny service accessibility or hinder service effectiveness.

1.    The director of administration, county health department, CMS unit and other major entity directors, and the hospital administrator are responsible for the development and implementation of their respective auxiliary aids plan that provides assisting devices, interpreters or readers and physical modifications to ensure the accessibility of programs and services to clients or potential clients with sensory (hearing and sight), speaking or mobility impairments. The Director of the Office of Equal Opportunity and Minority Health is the designated Title VI, Section 504 and ADA coordinator for the department and is responsible for the overall coordination and the development and implementation of the Department of Health Methods of Administration for ensuring the nondiscriminatory delivery of equally effective and equally accessible quality services. Clients and potential clients are generally provided services through the counties; therefore, each county specific auxiliary aids and limited English proficiency plan must cover persons in the respective geographic area. Such clients will be directed to the appropriate operating county for actual delivery of services.

2.    A copy of each county, hospital and the headquarters plan or update to the plan is submitted to the Office of Equal Opportunity and Minority Health by March 31 of each year.

3.    Minimum Requirements for the Auxiliary Aids and Limited English Proficiency Plan.

a.    A description of auxiliary aids available for use in each phase of the service delivery process (e.g., telephone inquiries, requests, intake interviews, service provision, counseling, emergency services, etc.) when the lack of such aids may in effect deny service accessibility or hinder service effectiveness.

b.    A list of the resources available (e.g., TTD, list of qualified interpreters, including Department of Health staff and qualified volunteers, deaf service centers, and other organizations serving persons with hearing, vision and mobility impairment) shall be maintained in each county, hospital and by each service provider with over 15 employees. The county health department director, hospital administrator and provider administrator shall designate a specific office of accountability to ensure proper dissemination of this information.

c.    A training requirement for direct services field staff, institutional staff and other staff who deal with the public, to include an awareness of hearing impairments and deafness; vision impairments and blindness; mobility and psychological impairment; the communication options available for auxiliary aids; how to access those aids; and the responsibility to provide reasonable accommodations to ensure that programs and services are equally accessible to and effective for persons with disabilities. Training shall be made available to contract service providers as appropriate.

d.    At a minimum, detailed procedures to be used by direct service staff in requesting appropriate auxiliary aids shall include:

(1)    How client needs are to be assessed.

(2)    Who is responsible for approving the request and obtaining the appropriate auxiliary aid.

(3)    A time standard for the provision of services. In some cases delaying services is not always practical or appropriate; therefore, provision should be made for communication alternatives when advance notice for an auxiliary aid is not given.

(4)    A full range of communication options with the selection of the option the person with the hearing, sight or mobility impairment believes is the most effective to ensure such persons are provided effective access to health care and other services. The range of options that must be provided at no cost to the person with the hearing impairment must include:

(a)    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.

(b)    Supplemental hearing devices.

(c)    Written communication.

(d)    Flash cards.

(e)    Staff training in basic sign language expressions relevant to emergency treatment.

(f)    At least one telecommunications device, or an arrangement to share a TDD line with other facilities.

(g)    Family members may be used only if they are specifically requested by the hearing impaired person.

(5)    A procedure for notifying clients and applicants of the availability of auxiliary aids and procedures for requesting an auxiliary aid.

(6)    A monitoring procedure for ensuring compliance with this regulation.

4.    When it is necessary to obtain auxiliary aids, every effort will be made to obtain them within the department’s current resources, including qualified volunteers and volunteer organizations. However, if an auxiliary aid is required and must be purchased or leased, payment will be made from the appropriate operating budget. Finance and accounting procedures govern the purchase and provision of interpreter services. A qualified interpreter will be paid fees in accordance with finance and accounting procedures.

5.    The following procedures are to be followed by Department of Health employees in providing auxiliary aids to ensure the accessibility of programs and services to clients or potential clients with sensory (hearing and sight), speaking or mobility impairments.

a.    Client needs are to be assessed through consulting with the client or potential client concerning his or her preferred communication mode, and if applicable with the assigned caseworker, counselor, parent, other family member, guardian or other representative and the auxiliary aids coordinator.

b.    The communication options for hearing impaired persons will include but not be limited to telecommunications devices for the deaf (TDD), telephone facsimile transmittal (FAX), phone amplifiers, sign language interpreters, flash cards, lip-reading, written notes, supplementary hearing devices, charts, signs or a combination of these.

c.    The Department of Health or provider administrative official with budget approval authority over the unit or facility involved, or the designated official as otherwise provided in the specific auxiliary aids plan has the responsibility for approving the request and obtaining the appropriate auxiliary aid. Financial management payment policies and procedures are to be followed.

d.    Auxiliary aids will be provided within two days of request or as otherwise required. Delaying services is not always practical or appropriate; therefore, provision will be made for communication alternatives when advance notice of a need for an auxiliary aid is not given.

e.    The use of auxiliary aids will be at no cost to the client. Finance and accounting procedures along with this procedure, the Americans with Disabilities Act Accommodations Manual and the appropriate auxiliary aids plan govern the purchase and provision of interpreter services.

f.    Meetings, conferences and seminars will be accessible to persons with sensory, speech or mobility impairments. Facilities used for meetings, conferences and seminars will be reviewed for accessibility by the unit sponsoring the activity in coordination with the designated Section 504 Coordinator or Auxiliary Aids and Limited English Proficiency Coordinator. When meetings, conferences or seminars are scheduled, information will be included in the advertisements, conference registration materials or meeting notices, that sensory impaired participants will be provided with necessary auxiliary aids at no cost to themselves. The information will include the name of a contact person and a date by which the person must request such assistance. The registration process should include a method for determining the number and type of disabled individuals (participants) needing assistance, as well as, the type of personal assistance requested.

g.    The Department of Health Nondiscrimination Policy and the hearing impaired poster will be displayed in each building housing headquarters, hospital, CMS and county employees at main entrances in lobby areas; in each facility serving clients at admission desks, waiting rooms and bulletin boards. The name, telephone number and TDD number for the designated Auxiliary Aids and Limited English Proficiency coordinator will be listed on the hearing impaired poster to assure accessibility to clients or potential clients, or their representatives. Descriptive information on the availability of assisting devices or aids will be included in announcements related to meetings, seminars, workshops and conferences, as well as, to services offered by headquarters, hospital and county units and by contracted service providers.

h.    County, hospital, CMS unit and headquarters employees and provider staff who provide direct services to clients will be trained on how to assist sensory impaired clients and potential clients in obtaining assisting devices and aids, or other reasonable accommodations. Such training will include:

(1)    Procedures for serving or accommodating hearing impaired, sight impaired and mobility impaired clients or potential clients.

(2)    Awareness of hearing impairments, deafness, speech impairments, sight impairments, blindness, reading impairments, dyslexia and mobility impairments.

(3)    Communication options available.

(4)    How to provide reasonable accommodations for qualified clients and potential clients, i. e., how to access or purchase auxiliary aids, interpreter services or physical modifications.

(5)    Requirements for making meetings, conferences and services accessible.

i.    Records relating to the auxiliary aids plan implementation, specifically including the methods and sample copies of information, such as brochures, letters, memoranda, newspaper notices, staff meetings or public service announcements, used to inform employees or clients of this nondiscriminatory policy will be documented and maintained for three years by the designated 504 coordinator for the subject program or service provider.

D.    Complaint Procedures. This section establishes uniform procedures for resolving complaints of discrimination filed against the Department of Health. These procedures apply to department employees, applicants for employment, clients, and potential clients who allege unlawful discrimination by reason of race, color, sex, marital status, religion, age, national origin or disabling condition.

1.    Employees, applicants for employment, clients and potential clients of the Department of Health who believe that they have been discriminated against may file a written complaint of discrimination.

a.    Employees and applicants for employment may file a written employment discrimination complaint within 365 days of the alleged discriminatory act with:

(1)    Office of Equal Opportunity and Minority Health
Department of Health
4052 Bald Cypress Way, Bin A00Tallahassee, FL 32399-1701
(850) 245-4002
TDD (850) 410-1451

or the local EEO coordinator

(2)    Florida Commission on Human Relations
325 John Knox Road
Building F, Room 240
Tallahassee, FL 32399-1570
(850) 488-7082

b.    Employees and applicants for employment may file a written complaint within 360 days of the alleged discriminatory act with the United States Equal Employment Opportunity Commission.

c.    Clients and potential clients may file a written complaint within 180 days of the alleged discriminatory act with:

(1)    Office of Equal Opportunity and Minority Health
Department of Health
4052 Bald Cypress Way, Bin A00
Tallahassee, FL 32399-1701
(850) 245-4002, TDD (850) 410-1451

or the local EEO coordinator

(2)    United States Department of Health and Human Services, Office of Civil Rights
Atlanta Federal Building
61 Forsyth Street
Atlanta, GA 30303
(404) 562-7222

(3)    United States Department of Agriculture
Food and Nutrition Service
61 Forsyth Street, SW, Suite 8T36
Atlanta, GA 30303
(404) 562-1801

(4)    United States Department of Justice
Civil Rights Division
Disability Section
Post Office Box 66738
Washington, D. C. 20035-6738
1-800-514-0301
TDD 1-800-514-0383

d.    The complaint must contain:

(1)    Basis for the complaint, e. g., race, color, religion, sex, age, national origin, disability, or retaliation.

(2)    Name, address and phone number of the person filing the charge (complainant).

(3)    Name and address of the employer or provider being filed against (respondent).

(4)    Description and dates of the alleged discriminatory act(s).

(5)    Be affirmed or signed by the complainant.

e.    Complaints filed with federal and state agencies are subject to federal and state laws governing such complaints. Final determination of the validity of the complaint will be made by that agency.

2.    The Office of Equal Opportunity and Minority Health is the department’s central intake point for all externally and internally filed complaints. Other Department of Health offices receiving such complaints directly are to immediately forward the complaints to the Office of Equal Opportunity and Minority Health.

3.    Complaint receipt.

a.    Internal complaints are complaints filed directly with the Office of Equal Opportunity and Minority Health or the local EEO coordinator. Upon receipt of a written complaint, the Office of Equal Opportunity and Minority Health will send written acknowledgement of the internal complaint to the complainant and will notify the headquarters administrator, county health department director, CMS unit or hospital administrator who has line responsibility for the alleged discriminatory official. The complaint will then be assigned and investigated.

b.    External complaints are complaints filed directly with another agency. Upon receipt of an externally filed complaint, the appropriate administrative official will be notified and the complaint will be assigned and investigated.

4.    Complaint Investigation.

a.    Within five calendar days of receipt of a complaint, the Office of Equal Opportunity and Minority Health will forward the written complaint along with a document request to the appropriate EEO coordinator or administrator responsible for the investigation. The document request will delineate each allegation and documents to be obtained.

b.    Another department representative may be designated as the investigator at the discretion of the county health department director, hospital administrator or headquarters official. If another investigator is assigned, the Office of Equal Opportunity and Minority Health will be informed in writing of the designated investigator and the reason.

c.    Within 30 calendar days of receipt of the complaint assignment, an investigative report will be prepared, submitted for review and approval, through the appropriate legal counsel, to the county health department director, hospital administrator, or appropriate headquarters official and returned to the Office of Equal Opportunity and Minority Health.

d.    The investigative report will include, but not be limited to, the following:

(1)    The complaint and any additional information which the complainant wishes to submit.

(2)    Affidavit(s) by any witnesses testifying on behalf of the complainant.

(3)    Affidavit(s) by the Alleged Discriminatory Official (ADO) in response to each allegation with any supporting documentation.

(4)    Affidavit(s) by any witnesses testifying on behalf of the ADO(s).

(5)    Statement of position by the respondent, together with any documents in support of that position.

(6)    Records and documents gathered in evidence from the respondent.

(7)    Investigator’s summary and recommendation of a finding of reasonable cause or no reasonable cause to believe that discrimination or retaliation has occurred as alleged.

e.    If the county health department director, hospital administrator, other appropriate official or the Office of Equal Opportunity and Minority Health determines the report to be insufficient, the report will be returned for further review or investigation. Any objections should be noted in writing to indicate the specific deficiencies cited or other reasons for rejection.

f.    Requests for extensions of the time to complete the investigative report may be made to the Office of Equal Opportunity and Minority Health through the appropriate official, county health department director or hospital official by the EEO coordinator whenever additional time is required to submit the investigative report. Reasons for the need for additional time and the anticipated completion date will be included in the request.

g.    Upon receipt of the investigative report, the Office of Equal Opportunity and Minority Health will review the report for sufficiency to determine if there is a need for additional information or immediate corrective action. The report and any addendum required to fully address the issues in the complaint and the Office of Equal Opportunity and Minority Health recommendation will be submitted along with the complaint summary to the department’s legal office for review.

5.    Complaint Decision and Disposition. Based on the investigative report, finding and recommendations, the Director of the Office of Equal Opportunity and Minority Health will determine the department’s position relative to each complaint.

a.    Internal Complaints.

(1)    If there is a finding of no reasonable cause, the complaint will be dismissed, the complaint file closed, and the complainant and ADO(s) notified of the decision. However, the complainant does have the option to file the complaint externally.

(2)    If there is a finding of reasonable cause, conciliation will be initiated by the Office of Equal Opportunity and Minority Health with the EEO coordinator, the appropriate administrative officials and the complainant.

b.    External Complaints.

(1)    If the department finds no reasonable cause, the Office of Equal Opportunity and Minority Health will prepare a position statement supporting this finding and will submit that statement along with supporting documentation to the external agency who will make the final determination of the complaint.

(2)    If the department finds reasonable cause, the Office of Equal Opportunity and Minority Health will initiate conciliation in coordination with the EEO coordinator, the appropriate department official, the Department of Insurance (Division of Risk Management) and the State Comptroller.

(3)    If the external agency finds reasonable cause, they will initiate conciliation coordinated internally by the Office of Equal Opportunity and Minority Health with the EEO coordinator, appropriate departmental official, the Department of Insurance (Division of Risk Management) and the State Comptroller.

6.    Retaliation Prohibited. No person shall intimidate, threaten, coerce, or discriminate against any individual for the purposes of interfering with any right or privilege secured by the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Americans with Disabilities Act of 1990 or any other state or federal civil rights laws, or because he or she participated in any manner in an investigation, proceeding or hearing under said laws.

E.    Training and Evaluation.

1.    Training.

a.    The Office of Equal Opportunity and Minority Health will ensure that appropriate civil rights compliance training and technical assistance are provided to the county, CMS unit and headquarters coordinators to include:

(1)    Annual EEO coordinators’ workshop.

(2)    Pre-service training on civil rights compliance responsibilities, including investigative techniques, to new EEO coordinators within 30 days after appointment.

b.    EEO coordinators will be responsible for provision of EEO training and orientation, as appropriate, to include:

(1)    New employee orientation.

(2)    In-service training for new employees who are serving on an EEO compliance committee, supervisors, and contract providers.

(3)    Training for contract managers, grants managers, other staff assigned civil rights compliance responsibilities and other employees as appropriate.

(4)    Training will consist of workshops, technical assistance conferences, as well as, the distribution of pamphlets, procedures, guidelines and other technical assistance materials.

2.    Evaluation.

a.    The Office of Equal Opportunity and Minority Health will assume the overall responsibility for evaluating compliance activities to determine the effectiveness of procedures used to maintain compliance.

b.    Compliance review and evaluation may also be scheduled with other review activities.

c.    County health department directors, CMS unit directors and the hospital administrator are responsible for the evaluation of county, CMS and hospital compliance activities to determine the effectiveness of procedures used to maintain and to assure county and institutional civil rights compliance.

d.    The evaluation process will be completed by on-site reviews of all programs and providers, reviews of civil rights compliance checklists, quality assurance reports, related data and surveys, including reviews by the Office of Equal Opportunity and Minority Health.

F.    Reports and Record Keeping. The reports and reviews required to implement each county’s civil rights compliance activities will be maintained and reviewed to determine the extent to which provisions of this procedure and the related civil rights compliance requirements have been followed.

1.    Reports.

a.    The Civil Rights Compliance Checklist will be completed by each provider and county program and submitted to the EEO coordinator by June 15 of each year for review.

b.    The Civil Rights Compliance Report will be completed by the EEO coordinator and submitted through the appropriate official to the Office of Equal Opportunity and Minority Health by July 20 of each year.

c.    The On-Site Validation Review Report will be completed as part of the validation review process.

d.    Auxiliary Aids and Limited English Proficiency Plans will be completed and submitted to the Office of Equal Opportunity and Minority Health by March 31 of each year.

2.    Record Keeping.

a.    All records, reviews, checklists, compliance agreements, corrective action plans, reviewer notes, review summaries and other documentation reflecting civil rights compliance activities will be maintained by the appropriate EEO coordinator.

b.    Documentation of the dissemination of the Department of Health nondiscrimination policy and procedures, including to whom sent or given, how and when it was distributed, and what information was provided will be maintained by the EEO coordinator.

G.    Nondiscriminatory Recruitment and Selection. Departmental employment procedures and practices will provide for the nondiscriminatory recruitment and selection of all employees to ensure the inclusion and full representation of minorities, women and individuals with disabilities in all Department of Health programs and activities.

1.    Review of Selections. Each hiring official and human resource officer will review and validate selection criteria to assure nondiscriminatory selection of applicants.

VIII.    Distribution List. Notification of Intranet location sent to the following:

Deputies
Division Directors
Executive Office Directors
Bureau Chiefs
County Health Department Directors/Administrators
Children's Medical Services Nursing Directors/Medical Directors
Human Resource Liaisons
EEO Coordinators
Policies and Procedures Library, hard copy
Web Manager, electronic copy

IX    History Notes. Replaces HRS 220-2, Revised 06-01-2001