CIVIL RIGHTS COMPLIANCE PLAN Children and Families Health Services Workforce Development DCF-F-155-E (R. 11/2017) F-00164 DETS-16706-E (R. 12/1/2013) Recipient Contact Information and Signature Page - APPENDIX A The same Recipient Contact Information and Signature Page previously completed for the CRC LOA should be used for the CRC Plan. Funding Relationship to DHS, DCF or DWD - APPENDIX B The same Funding Relationship to DHS, DCF or DWD form previously completed for the CRC LOA should be used for the CRC Plan. Funded Programs Checklist - APPENDIX C The same Funded Programs Checklist previously completed for the CRC LOA should be used for the CRC Plan. Data Collection Service Delivery Our agency has a system that records the following: The race, ethnicity, sex/gender, disability status, and primary language of participants/applicants (Self-identification by the applicant/participant is the Yes No preferred method of obtaining characteristic data) Number of potentially eligible or likely to be affected or encountered Yes No Number of LEP individuals encountered by phone vs. walk-in Yes No Language spoken and/or dialect of LEP participants Yes No Number of eligible LEP participants by separate programs and the Yes No frequency of encounters Interpretation needs and preferred language of LEP participants Yes No The number of times interpretation services were offered and provided to Yes No LEP individuals and the language group for the service The written translation of vital documents for LEP groups that meet the 5 Yes No percent or 1,000 threshold requirement Number of sign language interpretation requests received from deaf and hard Yes No of hearing participants Other accommodation requests and needs from participants with disabilities Yes No If you to any of the above questions, describe your plan for addressing the responded “No” requirement(s), including target dates for completion of milestones, below:
CIVIL RIGHTS COMPLIANCE PLAN Children and Families DCF-F-155-E (R. 11/2017) Health Services F-00164 Workforce Development DETS-16706-E (R. 12/1/2013) Recipient Contact Information and Signature Page - APPENDIX A The same Recipient Contact Information and Signature Page previously completed for the CRC LOA should be used for the CRC Plan. Funding Relationship to DHS, DCF or DWD - APPENDIX B The same Funding Relationship to DHS, DCF or DWD form previously completed for the CRC LOA should be used for the CRC Plan. Funded Programs Checklist - APPENDIX C The same Funded Programs Checklist previously completed for the CRC LOA should be used for the CRC Plan. Data Collection Service Delivery Our agency has a system that records the following: The race, ethnicity, sex/gender, disability status, and primary language of participants/applicants (Self-identification by the applicant/participant is the preferred method of obtaining characteristic data) Yes No Number of potentially eligible or likely to be affected or encountered Yes No Number of LEP individuals encountered by phone vs. walk-in Yes No Language spoken and/or dialect of LEP participants Yes No Number of eligible LEP participants by separate programs and the frequency of encounters Yes No Interpretation needs and preferred language of LEP participants Yes No The number of times interpretation services were offered and provided to LEP individuals and the language group for the service Yes No The written translation of vital documents for LEP groups that meet the 5 percent or 1,000 threshold requirement Yes No Number of sign language interpretation requests received from deaf and hard of hearing participants Yes No Other accommodation requests and needs from participants with disabilities Yes No If you responded “No” to any of the above questions, describe your plan for addressing the requirement(s), including target dates for completion of milestones, below:
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