Department of Human Services

In this corner:

DHS 2016 – 2019 Self Evaluation and Compliance Plan

September 2016 Transmittal ICF
Table of Contents
Executive Summary

Self Evaluation and Compliance Plan (Effective September 1, 2016)

APPENDICES

Appendix A 
Acts, Acronyms, and Definitions

Appendix B
DHS Policies and Procedures (4.10.1, 2, 3, and 4)

Appendix C
Sample Mission, Vision, Pledge, and Service Standards

Appendix D
Sample Publication and Form (Access Hawaii; Request for Auxiliary Aid)

Appendix E
Sample Translation (Tagalog; Chinese)

Appendix F 
Sample Notifications and Description of Data Sources
Program Accessibility for Persons with Disabilities Notice
The Americans with Disabilities Act Prohibits Discrimination Notice
Nondiscrimination Notice
Notice of Due Process Standards

Appendix G
Discrimination Complaint Procedure (DHS 6000 and 6006)

Appendix H 
Title VI Civil Rights compliance Checklist (Sample)

Appendix I
Title VI Coordinator Description

Appendix J
Related Resources and Sample Data Source Descriptions
HHS Finalizes Rule to Improve Health Equity Under the Affordable Care Act
(Section 1557 – Sex Discrimination) May 13, 2016
Sample Business Associate Agreement Provisions
Sample Data Source Descriptions

Affirmative Action Plan  2016-2019

• Affirmation Action Plan 2016-2019

Language Access Plan  2016-2018

• Language Access Plan 2016-2018

DHS Policies and Procedures  2016 Updates

• Discrimination Complaints
• Harrassment Prevention
• Opportunity to Participate
• Access

Mandatory Notices 2017

• Mandatory Notice Confirmation
• Access Hawaii Brochure (includes No cost Interpreter Services and Discrimination Complaint Notice)
• ADA Notice
• Breastfeeding in Public Accommodations Notice
• DIR Memo 17-01
• DIR Memo 17-02
• EEO and Supplement Genetic Information
• Employment Discrimination and Other Hawaii State Notices
• Fair Housing Notice
• Harassment Notice
• Justice for All Notice
• Non-Discrimination Affordable Care Act Section 1557
• Non-Discrimination Multilingual Notices
• Notice of Interpreter Services at No Cost
• Equal Opportunity Notice
• Rehabilitation Act, Section 504 Notices and Due Process Standards
• Right to Time and Place to Express Breast Milk
• Your Rights Under USERRA

Forms and Brochures

DHS 050 – Access Hawaii

DHS 5000 – Offer and Acceptance or Waiver of Free Interpreter Services

DHS 5050 – Interpreter Form and Code of Ethics

DHS 6000 Discrimination Complaint Form

• Complaint Form Instructions

DHS 6006 – Consent Release Form

DHS 6007 – Complaint Withdrawal Form

DHS 6008 – Auxiliary Aid Request Form

DHS RA-1  Request for Reasonable Accommodation for Employees and Applicants for Employment

• Instructions for RA-1 Request for Reasonable Accommodation

These forms are available in the following languages in Word 2007 and PDF OCR format:

• English
• Chinese
• Chuukese
• Korean
• Japanese
• Ilocano
• Marshallese
• Samoan
• Spanish
• Tagalog
• Vietnamese

Resources

• Court Interpreter List

Training and Development Presentations

For alternate formats, call or email Geneva Watts at 586-4955; gwatts@dhs.hawaii.gov

• Civil Rights Awareness Mandatory Training (2017)
• SNAP Program and FNS-113 – Civil Rights Awareness Training – ppt
  • PDF version

Nondiscrimination

– Chinese (Mandarin or Cantonese)
– Chukese
– English
– Ilocano
– Samoan
– Spanish
– Tagalog
– Vietnamese
– Visayan