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
- The Center did not accept the applicant's case.
- A client disagrees with the Center's decision to close his or her case
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