Form Dhs 6006 - Consent/release Form - Department Of Human Services State Of Hawaii printable pdf download

Form Dhs 6006 - Consent/release Form - Department Of Human Services State Of Hawaii

STATE OF HAWAII

DEPARTMENT OF HUMAN SERVICES

CONSENT / RELEASE FORM

Name:

Address:

Please read, initial, sign and date this form.

I understand that in the course of a preliminary inquiry or investigation, it might be necessary for the

Department of Human Services (DHS), Civil Rights Compliance Staff (CRCS) to reveal my identitty to persons

at the organization under investigation, including personal information that is gathered as a part of the

preliminary inquiry or investigation of my complaint. I understand that as a complainant, I am protected by

Federal regulations and DHS policies from retaliation for having taken action or participated in action to secure

rights protected by non-discrimination statutes. Confidentiality cannot be guaranteed.

CONSENT GRANTED



I have read and understand the above information and authorize DHS CRCS to reveal my

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identity to persons at the organization under investigation, and to Federal or State

if you give

agencies that provide financial assistance to the organization, and/or have responsibility

consent.

for civil rights compliance.



I authorize the DHS to receive material and information pertinent to the investigation of my

complaint. This release includes, but is not limited to: applications, case files, personal

records and medical records; and will be used only for authorized civil rights compliance

and enforcement activities.



I understand that I am not required to authorize this release, and I do so voluntarily.



This authorization is effective for one year from the date of the authorization.

CONSENT DENIED



I have read and understand the above information. I do not want the DHS CRCS to

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reveal my identity to the organization under investigation, or to review, receive, or discuss

if you deny

material and consent information pertinent to the investigation of my complaint.

consent.



I understand that by declining consent, it may make the investigation of my complaint

more difficult and, in some cases, may result in the investigation to be closed.

Signature

Date

RETURN signed and dated form to:

State of Hawaii

Department of Human Services

PERS/CRCS

P. O. Box 339

Honolulu, Hawaii 96809-0339

SEND questions to:

gwatts@dhs.hawaii.gov

DHS 6006 (06-2014)

Form Dhs 6006 - Consent/release Form - Department Of Human Services State Of Hawaii

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