La Porte County Grievance Form (Page 2 of 2) in pdf

La Porte County Grievance Form Page 2

La Porte County Grievance Form

Please read the attached Complaint, Grievance and Appeal Process Policy & Procedures

Please Print Clearly

Today’s Date: ________________

Grievant: _________________________________

Address: _______________________________________

City, State, Zip: ___________________________________

Individual Discriminated Against: ______________________________________

Address: ____________________________________

City, State, Zip: ________________________________________

Alleged Violation: Date(s) of Occurrence: _______________________________________________

Describe violation:

_____________________________________________________________________________________

Has complaint been filed with a State or Federal agency: YES ______ NO ________

Name of Agency: _____________________________________ Date Filed: ____________________

Contact Person: _______________________________________________

Address: _____________________________________________________

Phone: _______________________________

Grievant’s Signature: _________________________________________

For a complaint to be acted upon, it must be documented in writing with the complainant’s

signature and address. The initial complaint, whether verbal or written, should be directed to the

ADA Coordinator within (60) calendar days of incident.

Forms are available on the La Porte County’s website ( ) and located at the La

Porte County Complex, 555 Michigan Avenue, Suite 203, La Porte, IN, 46350. Alternate formats are

available upon request. If you require assistance completing this form please call: (219) 326-6808 Ext.

2298.

La Porte County Grievance Form Page 2