§125.APPENDIX A. Grievance Form

Grievance

Discrimination Based on Disability

 

It is the policy of the Office of the Attorney General to provide assistance in filling out this form.  If assistance is needed, please ask:

 

ADA Coordinator − Office of the Attorney General

State of Illinois Center, 100 West Randolph

Chicago, Illinois 60601

[phone] (Voice) [phone] (TDD)

 

Name: _______________________________________________________________________

 

Address:______________________________________________________________________

 

City, State and Zip Code:_________________________________________________________

 

Telephone No._______________

 

Program, Service, or Activity to which Access was Denied or in which Alleged Discrimination occurred:_________________________

 

Date of Alleged Discrimination: ________________________

 

Nature of Alleged

Discrimination:_________________________________________________________________

 

(Attach additional sheets, if necessary.  If the grievance is based on a denial of requested reasonable modification, please fill out the back of this form.)

 

I certify that I am qualified or otherwise eligible to participate in the program, service or activity and the above statements are true to the best of my knowledge and belief.

 

 

Signature		Date

 

Please give to the ADA Coordinator at the address listed above.

 

For Office Use Only

 

Date Received: ___________________        By: ______________________________

 

(BACK OF FORM)

 

Please fill out this part of the form if this grievance is based upon the denial of a requested reasonable modification.  A reasonable modification will be made to make programs, services and activities accessible.  Reasonable modifications could include such things as providing auxiliary aids and devices and changing some policies and requirements to allow an individual with a disability to participate.  This portion of the form should be filled in to the extent you know the answers.  The form may be submitted even if this portion is incomplete.

 

Reasonable modification requested:

 

The date the reasonable modification was requested:

 

The person to whom the request was made:

 

The reason for denial:

 

Estimated cost of modification (if an assistive device, such as a TDD or optical reader, or commodity or service to which a cost is readily known):

 

Why is the requested modification necessary to use or participate in the program, service or activity?

 

Alternative modifications which may provide accessibility:

 

Any other information you believe will aid in a fair resolution of this grievance.