Untitled Document

ADA GRIEVANCE FORM

Name: _________________________________________________________________

Address: _________________________________________________________________

Phone: (____) ______________________________________________________________

Please provide a complete description of your grievance.

Complaint: _________________________________________________________________

_____________________________________________________________________________

Please attach additional pages as needed.

Signature: ______________________________________ Date: ___________________

Please return to ADA Coordinator, EHS Building 179 Newell Drive for all ADA grievances.

For all ADA Coordinator grievances, return this form to the Equal Employment Opportunity Director, 337 Stadium.

Upon request, for persons with disabilities, assistance will be provided in completing this form. Contact the Americans with Disabilities Act Office, 179 Newell Drive, (352) 392-7056 (V), (352) 846-1046 (TDD) or 711.