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2. Title II of the Americans with Disabilities Act Section 504 of the Rehabilitation Act of 1973 Grievance Form
4. Grievant Name*
5. Email*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Home Telephone*
14. Business / Cell Phone
18. Representative Reporter
    This section is to be completed only if the aggrieved person is not the individual completing this form. Skip to the Grievance Details section if this does not apply to you.
20. Reporting Individual Name
21. Person(s) Affected by the Situation
23. Reporting Individual Address
25. City
26. State
27. Zip Code
29. Reporting Individual Preferred Telephone
33. Grievance Details
35. Program or Facility Alleged to Be Inaccessible*
36. Date the Situation Occurred*
    Date the Situation Occurred
38. Description*
    Describe the situation or way in which the program is not accessible, providing the name(s) where possible of the individuals who were involved in the situation.
40. Have efforts been made to resolve this complaint through the Request for Accommodation with the ADA Coordinator?*

    1. Yes

    1. No
41. Today's Date*
    Today's Date
43. What were the results?
Leave This Blank:


45. 1. Receive an email copy of this form.
46. Email address

    This field is not part of the form submission.

47. Submit Submit and Print

* indicates a required field