Americans with Disabilities Act Grievance Form
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Date:
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Name of grievant:
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Address of grievant:
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Telephone number of grievant:
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Name, address and telephone number of alternate contact person:
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Department alleged to have denied access:
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Please describe the particular way in which you believe you
have been denied the benefits of any service, program or activity
or have otherwise been subject to discrimination. Please specify dates,
times and places of incidents, and names and/or positions of employees
or other persons involved, if any, as well as names, addresses and
telephone numbers of any witnesses to any such incident. Attach additional
pages, if necessary.
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Proposed access or accommodation:
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If you wish, describe the way in which you feel access may be
had to the benefits described above, or that accommodation could be
provided to allow access.
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