Grievance Form (Americans With Disabilites Act)

AMERICANS WITH DISABILITES ACT (ADA) TITLE II GRIEVANCE FORM Grievant Information Grievant Name: Address: Home Phone (include area code): Business Phone (include area code): Mobile Phone (include area code): Alternative Contact Person (other than Grievant) Name: Address: Home Phone (include area code): Business Phone (include area code): Relationship To Client: Court Service, Program or Facility Allegedly in Violation Date and Location of Alleged Violation (dd/mm/yyyy) Description of Alleged Violation and Requested Remedy Has this case been filed with the Department of Justice or other government agency or court? Yes No If You Answered "Yes" to the Previous Question, Complete the Following Agency or Court: Address: Contact Person: Phone (include area code): Date Filed: Other Comments Signature: ________________________________________________ Date: __________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com