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Discrimination Grievance Report Form Instructions


The purpose of this form is to assist you in filling out a discrimination report in the event you feel your civil rights have been violated by an employee of T.J. Regional Health. If you do not understand a question or require assistance completing this form, please call the T.J. Regional Health Section 1557 Coordinator at (270) 651-4242.

You are not required to use the attached form. You may write a letter instead. If you write a letter, it must contain all of the information requested in this form and be signed by you or an authorized representative. Incomplete information may delay the processing of your complaint.

You may also send a complaint by fax to (270) 651-4371


A discrimination complaint must be filed not later than 60 days following the date you were made aware of the alleged discrimination. Complaints sent by mail are considered filed on the date the complaint was signed, unless the date on the complaint letter differs by seven days or more from the postmark date, in which case the postmark date will be used as the filing date. Complaints sent by fax will be considered filed on the day the complaint is received.


No employee of T.J. Regional Health shall intimidate, threaten, harass, coerce, discriminate against, or otherwise retaliate in any way against anyone who has filed a complaint of alleged discrimination or who participates in any manner in an investigation or other proceeding raising claims of discrimination.

To complete and submit a Discrimination Grievance Report Form, please click here.