Section 1 of 1 in this document
ADA Accommodation/Gievance Form
Full Name
First Name
Last Name
Address Autocomplete
Address or Location
Email
Phone Number
I wish to file
A request for Accommodation
A grievance
Program Alleged to be Inaccessible:
Address of Alleged Place to be Inaccessible:
Street Address
City
State
Zip
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
No
Additional space for answers or comments:
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