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ADA-504 Grievance Form
Americans with Disabilities Act
Section 504 of the Rehabilitation Act of 1973
Grievance Form
Instructions: Please fill out this form completely. A printed or typed response is recommended.
Sign and return to the address on last page by email, fax, mail or in person. If you need an
accommodation to complete or submit this form, please contact the ADA Coordinator as
indicated on this form.
1. Complaintant:
Address:
City, State and Zip Code:
Telephone: Home: Business:
2. Person Discriminated Against: (if other than the complainant):
Address:
City, State, and Zip Code:
Telephone: Home: Business:
3. Department or person which you believe has discriminated (if known):
Name:
Address:
City, State and Zip Code:
Telephone Number:
When did the discrimination occur? Date:
4. Describe the acts of discrimination providing the name(s) where possible of the individuals
who discriminated:
5. Have efforts been made to resolve this complaint?
Yes No