Customer Service Incident Report

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Filing Customer Service or Privacy Complaints or a Report of Discrimination If you have a complaint regarding the services you received from the Department of Human Services (DHS), the protection of your private information or feel you have been discriminated against, this document will explain the process to file a report of discrimination, or a customer service or privacy complaint.. Please print clearly: Name of person with the complaint: Phone/TTY number: Email: Mailing address: Date of birth: City: State: ZIP: Last 4 digits of Social Security number: Are you filing on behalf of someone else Yes No Your name: Phone: Please mark the reason for your complaint (check all that apply): You did not receive good customer service You believe your personal information was not kept confidential You believe you were discriminated against because of: Age Gender Sexual orientation Political beliefs Religion Disability Race, color or national origin Sexual orientation is protected by the State of Oregon, but not federal laws..

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