ADA/Section 504 Grievance Form

Background Information

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Your full name:

Your phone number:

Your email address:

Email address must be of a valid format.

Nature of this grievance(Required):

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Urgency of this report(Required):

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Date of violation(Required):

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If multiple dates, please provide date of most recent occurrence

Location of incident(Required):

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Specific location:

Involved Parties

Please provide the name of the office, department, employee or individuals involved below, providing as much information as is known to you at the time of completing this form.

Name or Department

Select the person, office, department or employees role

ID Number

Email address

Questions

Please provide clear and concise answers to the questions below that pertain to your grievance.

If you have experienced harassment or discrimination based on your disability, please provide a statement outlining the harassment experienced and the steps, if any, that you have taken to resolve the issue. This field is required.

If the nature of this grievance pertains to your approved accommodations, please specify the accommodations that you had requested and how those accommodations failed to meet your requirements. This field is required.

If the nature of this grievance pertains to the College’s online technology, please specify the particular area of technology (website, online learning, multi-media, overall accessibility, etc.), and include any links relating to area where accessibility issue occurred. What limitations did you encounter as a result of those difficulties and the step taken to resolve the issue? This field is required.

If the nature of this grievance pertains to the College’s physical construction or College grounds (i.e. building/classroom/office access, parking, inoperative elevator), please specify the difficulty that you experienced and the steps taken to resolve the issue. This field is required.

Please provide your affiliation with the College.(Required)

Student Faculty Staff Visitor Applicant Other

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Supporting Documentation

If you have any supporting documentation, pictures etc. please include them as attachments to this submission. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

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Background Information

Involved Parties

Questions

Supporting Documentation

Submission