A Grievance Form

Section 125 Section 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 (312) 814-7123 (Voice) (312) 814-3374 (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.