Department of Health
John J. Dreyzehner, MD, MPH, Commissioner

Title VI Forms

Assurance of compliance with Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973. Title IX of the Education Amendments of 1972 and the Age Discrimination Act of 1975. The Applicant provides this assurance in consideration of and for the purpose of obtaining Federal grants, loans, contracts, property, discounts or other Federal financial assistance from the Department of Health and Human Services.

Assurance of Compliance (HHS-690)

Title VI Compliance Questionnaire (PH-3436)

In accordance with Federal law and U.S. Department of Agriculture policy, this institution prohibits discrimination against persons based on their race, color, national origin, sex, age, or disability. Any person or representative alleging discrimination based on a prohibited basis has the right to file a complaint within 180 days of the alleged discriminatory action with the Tennessee Department of Health.

Discrimination Complaint (PH-3814)

Las leyes federales prohíben la discriminación de cualquier persona basado en su raza, color o país de origen. Usted tiene el derecho de presentar una queja al Ministerio de Salud de Tennessee si piensa que le discriminaron por alguna de estas razones.

Queja por discriminación (PH-3814S) (Español)

Tennessee Department of Health (TDH) Employees and Sub-Recipients of Contracts from the TDH

Title VI of the Civil Rights Act of 1964 is a national law that protects persons from discrimination based on their race, color, or national origin in programs and activities that receive federal financial assistance. In order for the Tennessee Department of Health to maintain compliance, a concentrated effort must be made to educate and train all departmental employees annually.

To streamline the process, an annual on-line Refresher training module (30 minutes including test) for employees has been developed.  Click on the link below (register if you are new to the LifePath site, then go back to the sign-in page), sign in and click on the Refresher module. After viewing the slides, go back to the “home” page and click on the – Test. After passing the test, go back to the “home” page and click on print Certificate. The Certificate will automatically print your name, the date, etc.; give the Certificate to your supervisor for your personnel (Human Resources) file.

***NOTE: All Sub-recipients and New Hires are to take the “Sub-recipient and New Hires Module.” Other TDH employees may also choose this module; it is 25 minutes longer (videos included) than the Refresher module. For questions or concerns, contact Luvenia Butler, Title VI Compliance Officer, TDH, Luvenia.Butler@tn.gov or (615) 741-9421.

LifePath - TN Public Health Training Center