ADA Accommodation/Gievance Form

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Address or Location

Phone Number

I wish to file

A request for Accommodation

A grievance

Program Alleged to be Inaccessible:

Phone Number of Alleged Place to be Inaccessible:

Describe the acts of alleged discrimination or way in which the program is not accessible, providing the name(s) where possible of the individuals who allegedly discriminated.

Have efforts been made to resolve this complaint through the Department in which the Alleged discrimination occurred?

Yes

Additional space for answers or comments:

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