A Grievance Form

Section 925 Section 925.APPENDIX A  Grievance Form GRIEVANCE FORM ILLINOIS ENVIRONMENTAL PROTECTION AGENCY GRIEVANCE DISCRIMINATION BASED ON DISABILITY It is the policy of the Illinois Environmental Protection Agency to provide assistance in filling out this form.  If assistance is needed, please ask. NAME: ADDRESS: CITY, STATE AND ZIP CODE TELEPHONE NO. VOICE TDD The Best Means and Time for Contacting: Program, Service, or Activity to which Access was Denied or in which Alleged Discrimination Occurred: Nature of Alleged Discrimination: (Attach additional sheets, if necessary.  If the grievance is based on a denial of a requested reasonable modification, please fill out the following page.) 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 fill out this part of the form if this grievance is based on the denial of a requested reasonable modification.  Reasonable modifications could include such things as providing auxiliary aides and devices and changing some policies and/or requirements to allow an individual with a disability to participate. This form should be filled in to the extent you know the answers.  It may be submitted even if incomplete. Reasonable Modification Requested: The Date the Reasonable Modification was Requested: The Person to whom the Request was Made: The Reason for the Denial: Estimated Cost of Modification (If an Assistance 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: Please give to the Designated Coordinator of the Americans With Disabilities Program. For Office Use Only Date Received:  ___________________        By:  ___________________________________