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ADA Grievance Form

Name

First

Last

Address

Street

City

State

Zip

Phone Number

Type in your phone number (###-###-####).

Email Address

Confirm

Date of Alleged Discrimination

Date the alleged discriminatory act or decision occurred.

Time of Alleged Discrimination

Time the alleged discriminatory act or decision occurred.

Court Location

Location of alleged discrimination.

Court Program, Service, or Persons Involved

Name of the court program, service, or names and positions of any court employees involved that is the subject of this grievance. Please include all relevant information.

Nature of Disability

Describe type of accommodation requested.

Description

Describe the alleged discriminatory act or decision (please be specific).

I certify that the above information is accurate.

Yes*

Enter the code shown above in the box below.

ADA Grievance Form

Complainant Information

Grievance