Below are some reminders for Service Providers when completing the HS 2125 Attestation Form for license renewals. For the Civil Rights Compliance Attestation, click here for HS2125.
Regarding Question 2: The contact email you provide is the email address that will be used to contact you if corrective action or additional information is needed. Please ensure that a proper contact is used or that any requests from the Bureau of Equal Opportunity (BEO) will be forwarded to someone who can provide the additional information.
Regarding Question 4: All providers should update their “Non-Discrimination in Employment” and “Non-Discrimination in Services” policy statements to include current contact information and required agencies. If updating this contact information/addresses is the only change made to your civil rights policies, procedures, or the facility’s non-discrimination policy statements, then you should check the box indicating “The facility has NOT changed and/or updated the documents, referenced above in Question 4, submitted to the Department.” If other changes have been made, please check the other box for Question 4 and submit samples of the affected policies/procedures. Click here for the “Sample Policies” for the contact information that should be used.
Regarding Question 6: If you indicate that your facility HAS had any complaints of discrimination filed against it with PHRC, BEO, EEOC, or OCR with the last 12 months, please provide the following information along with your attestation for each complaint filed:
- Date filed
- Agency filed with (PHRC, EEOC, etc)
- Alleged act of harm and protected class
- Current status (open or closed – if closed, include finding/outcome)
- Copies of the complaints filing/notices from the investigating entity(ies)
- Facility response(s) to the complaint filings
- Copies of your policies and procedures (to include any employee or client handbooks) regarding discrimination, sexual harassment and providing accommodations
- Copies of your advertisements including non-discrimination clause
For a renewal Certificate of Compliance/license application, the following apply:
- Office of Children, Youth, and Families (OCYF) – the renewal application and the Civil Rights Compliance Attestation (HS2125) should be emailed to: [email protected]
- Office of Mental Health and Substance Abuse Services (OMHSAS) – the renewal application and the Civil Rights Compliance Attestation (HS2125) should be emailed to: [email protected]
- Office of Long-Term Living (OLTL), BHSL, Personal Care Homes (PCH) & Assisted Living Residences (ALR) – if an electronic payment for the application fee is made, see instructions attached, then the renewal application and the Civil Rights Compliance Attestation (HS2125) should be emailed to: [email protected]. If submitting a check or money order for the renewal application fee, then the renewal application fee, renewal application and the Civil Rights Compliance Attestation (HS2125) must be mailed together to: DHS, BHSL, Room 623, PO Box 2675, Harrisburg, PA 17105-2675.
- Office of Developmental Programs (ODP) – the renewal application must be completed in the Certification and Licensing System (CLS) portal as usual but the Civil Rights Compliance Attestation (HS2125) must be emailed to: [email protected]
When emailing the above Offices, include the following in the subject line of the email: REASON – AGENCY/FACILITY NAME – LICENSE/CERTIFICATE NUMBER
- The reason can be RENEWAL, QUESTION, REQUEST, REVISION, etc
Office of Child Development and Early Learning (OCDEL) – Day Care Providers – FOR INFORMATION ON RENEWAL PROCEDURES, CONNECT DIRECTLY WITH THE BUREAU OF CERTIFICATION SERVICES, ALL QUESTIONS AND CORRESPONDENCE SHOULD BE DIRECTED TO [email protected] OR YOU CAN CONNECT WITH YOUR REGIONAL OFFICE. VIEW THE REGIONAL MAP HERE.
Thank you for your patience and cooperation as we transition to new procedures and electronic processing.
