HAWAII DISABILITY RIGHTS CENTER

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APPLICANT AND CLIENT APPEAL FORM

If HDRC decided not to open a new case for you; or if HDRC decided to close your existing case; and you disagree with HDRC's decision, please complete this Appeal Form.
APPLICANT OR CLIENT REPRESENTATIVE
Name Name
Telephone Telephone
E-mail E-mail
Street Address Street Address
City/State/Zipcode City/State/Zipcode
1. What decision of HDRC are you appealing? What date was this decision made?
2. Why do you believe the decision should be changed?
Designation of Representative: Representatives must provide a copy of a court order designating them as a guardian or conservator; or the following designation, signed and dated by the Appellant
  • I designate as my representative in this appeal.

  • Signature of Appellant: Date:

Please use the enclosed envelope to return this form to:

APPLICANT AND CLIENT APPEAL FORM

1132 Bishop Street , Suite 2102, Honolulu, Hawaii 96813

HAWAII DISABILITY RIGHTS CENTER

APPLICANT AND CLIENT APPEAL INSTRUCTIONS

Applicants or clients of the Center have a right to appeal a decision of the Center in the following circumstances
  • The Center did not accept the applicant's case.
  • A client disagrees with the Center's decision to close his or her case
Applicants and clients using this appeal process are referred to as 'Appellants." Appellants will be treated respectfully by Center representatives at each step and will be guaranteed that there will be no retaliation for invoking this process. The Center will provide assistance with reasonable accommodations or auxiliary aids and services necessary for processing the complaint.

Step 1. A written or oral appeal should be made to the Center within 30 days of the decision or action that prompted the appeal. The appeal shall include the name, address, and telephone number of the Appellant; the decision that is being appealed, and a description of the reasons why the Appellant believes the decision should be changed.

An Appellant may appeal orally. However the Center shall record any oral complaint on a standard recording device

An appeal must be in writing if filed by an Appellant's representative. If the Appellant is represented by another person (not an attorney, or parent where the Appellant is a minor) the appeal shall include either: (1) a copy of a court order designating the representative as a guardian or conservator; or (2) a designation of representative, on the form which shall be provided by the Center and signed by the Appellant.

The Center shall appoint a staff member who was not involved in the original decision to respond to the Appellant in person, by telephone, by letter, or by tape and attempt to resolve the dispute. The assigned staff shall provide a final written decision within 30 days of the date the appeal was received by the Center

Step 2. If the Appellant is not satisfied with the decision of the Center in step 1 above, the Appellant may request a review o f the decision on appeal by the Board of Directors of the Center. Such request for review shall be made within 30 days of the date of the final written decision of the assigned staff on the Appeal.

A Request for Review shall be addressed directly to the Executive Director of the Center, and shall be submitted either in writing, or in the form of the original appeal. Within 10 days following receipt of the Request for Review, the Executive Director shall schedule the hearing for not less than 10, nor more than 45 days following the receipt of the Request for Review. The Appellant and Appellant's Representative (if any) shall be permitted to attend this hearing. The decision of the Board will be sent in writing or by oral recording within five working days following the meeting. The decision of the Board is final.

Send all Correspondence, Notices and Appeals to:

EXECUTIVE DIRECTOR

Hawaii Disability Rights Center

1132 Bishop Street, Suite 2102, Honolulu, HI 96813