Grievance Form

Language or Disability Access Grievance Form

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Date

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Name

Best Means of Contacting (check one)

Mail

Telephone

E-mail

Best Time for Contacting

Address

City

State

Zip Code

Telephone Number

Telephone Type

Voice

TDD

E-mail Address

Program, Service or Activity to which access was denied or in which alleged discrimination occurred

Nature of the Alleged Discrimination

Please fill out this part of the form if this grievance is based on the denial of a requested reasonable accommodation. Please include in this box the information sought by the form provided at 4 Ill. Adm. Code Part 925, see link to form below.

Documents

4 Ill. Adm. Code Part 925 Appendix A

Grievance Form

Language or Disability Access Grievance Form

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Grievance Form

Language or Disability Access Grievance Form

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Policies

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