B.C.S. Adult Day Services

B.C.S. A.D.S. is located right next to/behind our main office at 220 Morton St. Jackson, Ohio 45640.

Buckeye Community Service ADS key goals are focused on
– Vocational Habilitation
– Adult Daily Living Skills
– Recreational Activities

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Notifying the Public of Rights Under Title VI
Buckeye Community Services, Inc.
• Buckeye Community Services, Inc. operates its programs and services without regard to
race, color, and national origin in accordance with Title VI of the Civil Rights Act. Any person
who believes she or he has been aggrieved by any unlawful discriminatory practice under
Title VI may file a complaint with the Executive Director.
• For more information on Buckeye Community Services’ civil rights program, and the
procedures to file a complaint, contact (740) 286-5039; email beyecserv@bcs77.org; or visit
our administrative office at 220 Morton Street, Jackson, OH 45640. For more information,
visit www.buckeyecommunityservices.org.
• For transportation-related Title VI matters, a complainant may file a complaint directly with
the Ohio Department of Transportation by filing a complaint with the Office of Equal
Opportunity, Attention: Title VI Coordinator, 1980 West Broad St., Columbus, OH 43223.
• For transportation-related Title VI matters, a complainant may file a complaint directly with
the Federal Transit Administration by filing a complaint with the Office of Civil Rights,
Attention: Title VI Program Coordinator, East Building, 5th Floor-TCR, 1200 New Jersey
Ave., SE, Washington, DC 20590.
• If information is needed in another language, contact (740) 286-5039

 

Section I:
Name:
Address:
Telephone (Home): Telephone (Work):
Email Address:
Accessible Format
Requirements?
Large Print Audio Tape
TDD Other
Section II:
Are you filing this complaint on your own behalf? Yes* No
*If you answered “yes” to this question, go to Section III.
If not, please supply the name and relationship of the person
for whom you are complaining:
Please explain why you have filed for a third party:
Please confirm that you have obtained the permission of the
aggrieved party if you are filing on behalf of a third party.
Yes No
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Section IV
Have you previously filed a Title VI complaint with this
agency?
Yes No
Section V
Have you filed this complaint with any other Federal, State, or local agency, or with any Federal
or State court?
[ ] Yes [ ] No
If yes, check all that apply:
[ ] Federal Agency:
[ ] Federal Court [ ] State Agency
[ ] State Court [ ] Local Agency
Please provide information about a contact person at the agency/court where the complaint was
filed.
Name:
Title:
Agency:
Address:
Telephone:
Section VI
Name of agency complaint is against:
Contact person:
Title:
Telephone number:
You may attach any written materials or other information that you think is relevant to your
complaint.
Signature and date required below.
_________________________________ ________________________
Signature Date
Please submit this form in person at the address below, or mail this form to:
Buckeye Community Services, Inc. Title VI Coordinator
220 Morton Street
Jackson, OH 45640