File: ACE-E-2
Nondiscrimination on the Basis of Handicap/Disability
(Grievance Form)
Date:___________________
1. Name of Grievant:_____________________________Title:_______________________
School:________________________________________________________________
Address:
_______________________________________________________________
______________________________________________________________________
Phone:________________________________________________________________
Summary
of Grievance
2. ______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
If others are affected by the possible
violation, please give their names and/or
positions:_______________________________________________________________
______________________________________________________________________
3. Your suggestions on resolving the complaint:__________________________________
______________________________________________________________________
______________________________________________________________________
4. Please describe any corrective action you
wish to see taken with regard to the
possible violation. You may also provide other information
relevant to this
grievance.______________________________________________________________
______________________________________________________________________
_____________________________________________
__________________
Signature
of Grievant Date
_________________________________________ _________________
Signature
of Person Receiving Grievance Date
Issued: