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U.S. Department of Health and Human Services
Office for Civil Rights
Complaint Portal: Civil Rights

Complaint Portal – File a Civil Rights Complaint
Form Approved: OMB No. 0945-0002
Expiration Date: 11/30/2022

ComplainantComplaint DetailsAdditional InformationSignatureConsentReview and Submit
Please check the information on this page is correct and click the Submit button at the bottom to submit the complaint.

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* Your First Name: CliffordRay * Your Last Name: Hackett
Phone:
Phone Number Usage
Street Address Line 1:* 1055 Kinoole
Street Address Line 2:
* City: Hilo
* State:Hawaii Country:USA * ZIP: 96720 Email Address (If available): 3659745

Are you filing this complaint for someone else?: No
* I believe that I have been (or someone else has been) discriminated against on the basis of::
Race / Color / National Origin
Age
Religion / Conscience
Sex
Disability

Who or what agency or organization do you believe discriminated against you (or someone else)?
* Person or Agency/Organization?: Agency/Organization
Agency/Organization: CHCC (Commonwealth Health Care)
* Street Address Line 1: General Delivery
Street Address Line 2:
* City: Saipan CNMI
* State:New Hampshire Country:USA ZIP: 96950
Phone:
Phone Number Usage

* When do you believe that the civil right discrimination occurred?
Date(s) Selected:
Violation Date
01/19/2021

Describe briefly what happened. How and why do you believe that you have been (or someone else has been) discriminated against? Please be as specific as possible.. (Attach additional pages as needed)
After I requested other option than the dangerous nasal swab such as oral test or full quarantine A police officer broke into my room and arrested me on the false charge of obstructing justice and the test was forced on me in jail by police officers and hospital nurses
Filing a complaint with OCR is voluntary. However, without the information requested above, OCR may be unable to proceed with your complaint. We collect this information under authority of Section 1557 of the Affordable Care Act, Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, Title IX of the Education Amendments of 1972, the Age Discrimination Act of 1975, Title II of the Americans with Disabilities Act and their implementing regulations. It is illegal for a recipient of Federal financial assistance from HHS to intimidate, threaten, coerce, discriminate or retaliate against you for filing a complaint or for taking any other action to enforce your rights under these Federal civil rights laws. OCR also collects information under authority of Section 1553 of the Affordable Care Act, the Church Amendments, the Coats-Snowe Amendment, the Weldon Amendment, the Religious Freedom Restoration Act, as well as other Federal civil rights, conscience protections and religious liberty statutes. It may also be illegal for a recipient of Federal financial assistance from HHS to intimidate, threaten, coerce, discriminate or retaliate against you for filing this complaint or for taking any other action to enforce your rights under these Federal laws. We will use the information you provide to determine if we have jurisdiction and, if so, how we will process your complaint. Information submitted on this form is treated confidentially and is protected under the provisions of the Privacy Act of 1974. Names or other identifying information about individuals are disclosed when it is necessary for investigation of possible discrimination, for internal systems operations, or for routine uses, which include disclosure of information outside the Department of Health and Human Services (HHS) for purposes associated with civil rights compliance and as permitted by law.

You are not required to use this form. You also may write a letter or submit a complaint electronically with the same information. To submit an electronic complaint, go to OCR’s web site at: www.hhs.gov/civil-rights/filing-a-complaint/index.html or www.hhs.gov/conscience/complaints/index.html. To mail a complaint, please send to HHS Office for Civil Rights, Centralized Case Management Operations, 200 Independence Avenue, S.W., Suite 515F, HHH Building, Washington, D.C. 20201.
* Signature: AGREE: I have read, understand, and agree to the above.
Do you need special accommodations for OCR to communicate with you about this complaint?
Large Print
Electronic mail

If we cannot reach you directly, is there someone we can contact to help us reach you?
No entries

Have you filed your complaint anywhere else? If so, please provide the following . (Attach additional pages as needed )
Filed Elsewheres:
Person/Agency/Organization/Court Name Date Filed Case Number (If known)
No records found

To help us better serve the public, please provide the following information for the person you believe was discriminated against (you or the person on whose behalf you are filing).
Ethnicity: Not Hispanic or Latino
Race:
White
Primary Language Spoken (if other than English):

How did you learn about the Office for Civil Rights?
HHS Website/Internet Search
COMPLAINANT CONSENT FORM

The Department of Health and Human Services’ (HHS) Office for Civil Rights (OCR) has the authority to collect and receive material and information about you, including personnel and medical records, when they are relevant to its investigation of your complaint.

To investigate your complaint, OCR may need to reveal your identity or identifying information about you to persons at the entity or agency under investigation or to other persons, agencies, or entities. In some circumstances, OCR may refer your complaint to another government agency, as warranted.

The Privacy Act of 1974 protects certain federal records that contain personally identifiable information about you and, with your consent, allows OCR to use your name or other personal information, if necessary, to investigate your complaint.

Consent is voluntary, and it is not always needed in order to investigate your complaint; however, failure to give consent is likely to impede the investigation of your complaint and may result in the closure of your case.

Additionally, OCR may disclose information, including medical records and other personal information, which it has gathered during the course of its investigation in order to comply with a request under the Freedom of Information Act (FOIA) and may refer your complaint to another appropriate agency.

Under FOIA, OCR may be required to release information regarding the investigation of your complaint; however, we will make every effort, as permitted by law, to protect information that identifies individuals or that, if released, could constitute a clearly unwarranted invasion of personal privacy.

OCR will use any applicable protections in that law to safeguard information which could identify you, or other individuals, or that, if released, could constitute a clearly unwarranted invasion of personal privacy. OCR may be required to release some information regarding the investigation of your complaint under the Freedom of Information Act (FOIA), however, information concerning your complaint which could reveal your identity is protected from disclosure to third party requesters under FOIA.

Please read and review the documents entitled, Notice to Complainants and Other Individuals Asked to Supply Information to the Office for Civil Rights (PDF) and Protecting Personal Informations in Complaint Investigations (PDF) for further information regarding how OCR may obtain, use, and disclose your information while investigating your complaint.

In order to expedite the investigation of your complaint if it is accepted by OCR, please read, sign, and return one copy of this consent form to OCR with your complaint. Please make one copy for your records.
As a complainant, I understand that in the course of the investigation of my complaint it may become necessary for OCR to reveal my identity or identifying information about me to persons at the entity or agency under investigation or to other persons, agencies, or entities.
I am also aware of the obligations of OCR to honor requests under the Freedom of Information Act (FOIA). I understand that it may be necessary for OCR to disclose general information which it has gathered as part of its investigation of my complaint, excluding personally identifiable information.
In addition, I understand that, as a complainant, I may be covered by the Department of Health and Human Services’ (HHS) regulations which protect any individual from being intimidated, threatened, coerced, retaliated against, or discriminated against because he/she has made a complaint, testified, assisted, or participated in any manner in any mediation, investigation, hearing, proceeding, or other part of HHS’s investigation, conciliation, or enforcement process.
* Consent Selection:
CONSENT: I have read, understand, and agree to the above and give permission to OCR to reveal my identity or identifying information about me in my case file to persons at the entity or agency under investigation or to other relevant persons, agencies, or entities during any part of HHS’ investigation, conciliation, or enforcement process.
File Uploaded:
File Name Size (Byte) File Type
No records found
Please review the information on this page for accuracy. When finished, please select the "Submit This Complaint" button at the bottom to submit the complaint.
Please do not fax, email, or mail a copy of this complaint to us as that may delay the processing of your complaint.

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If you need help filing a civil rights, conscience and religious freedom, or health information privacy complaint, please email OCR at OCRMail or call 1-800-368-1019. We provide alternative formats (such as Braille and large print), auxiliary aids and services (such as a relay service), and language assistance.

If you need other information on this web site translated or provided in alternative formats, please email us at OCRMail.

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