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Civil Rights Complaint

  1. Kansas Department of Health and environment
  2. 1000 SW Jackson St.,
    Suite 560
    Topeka, KS 66612-1368

  3. Civil Rights Complaint 

  4. Are you filing this complaint out for someone else?

  5. Who or what agency or organization do you believe violated these rights?

  6. When do you believe the civil rights violation occurred?

  7. Briefly describe what happened. How and why do you believe your (or someone else’s) civil rights were violated, or the privacy rule otherwise was violated? Please be as specific as possible.

  8. Please sign and date this complaint. You do not need to sign if submitting this form electronically because electronic submission represents your signature.
  9. (mm/dd/yyyy)

  10. KC-6501

  11. Leave This Blank:

  12. This field is not part of the form submission.