Highland Community College Americans With Disabilities Act (Ada) Complaint Form printable pdf download

Highland Community College Americans With Disabilities Act (Ada) Complaint Form

Highland Community College

Americans with Disabilities Act (ADA) Complaint Form

Individuals protected by the Americans with Disabilities Act with concerns/complaints

about Highland Community College’s ADA compliance should fill out this form and

submit it to one of the ADA compliance officers listed under the ADA and 504

COMPLIANCE section on the ADA Services web page.

Name: ________________________________________ Telephone: (____) ________

Address: _____________________________________________________________

______________________________________________________________________

CHECK ONE: [ ] student [ ] employee [ ] job applicant [ ] other

Description of Disability:

___________________________________________________________________

Description of barriers to services, programs, facilities or employment:

___________________________________________________________________

Describe any contacts made with Highland Community College representatives

regarding this problem:

___________________________________________________________________

Describe the remedy or accommodation requested:

____________________________________________________________________

SIGNATURE OF COMPLAINANT: _________________________ DATE: __________

SIGNATURE OF PREPARER: ____________________________ DATE: __________

Courtesy of Lane Community College

Highland Community College Americans With Disabilities Act (Ada) Complaint Form