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Civil rights questionnaire for nursing homes form

Civil rights compliance questionnaire 2026

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4.8 out of 5

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The document is a Civil Rights Compliance Questionnaire designed for facilities providing personal care and child day care services. It requires information on the facility's nondiscrimination policies in employment and service delivery, methods of communication with non-English speaking clients, accessibility for individuals with disabilities, and procedures for filing discrimination complaints. The questionnaire aims to ensure compliance with civil rights laws and promote equitable treatment across various demographics.

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Click ‘Get Form’ to open the civil rights compliance questionnaire in the editor.
Begin by filling in the 'Certificate/Licensing Number' and indicate whether this is a new application or a renewal.
Select the type of system you are operating: Multi-facility, Multi-type, Single site, or Other. Provide the legal entity name and responsible official's details.
Complete the program information including address, city, county, state, and phone number for your facility.
Answer the nondiscrimination policy questions thoroughly. For each question, check 'Yes' or 'No' and provide explanations where required.
If additional space is needed for answers, attach a separate sheet and denote your license number on it.
Review all entries for accuracy before submitting your completed questionnaire through our platform.

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Versions	Form popularity	Fillable & printable
2008	4.8 Satisfied (141 Votes)

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