Grievance FORM

I am a current or former student at EVCC.

I have attempted to resolve this complaint informally without an acceptable outcome.

Approximate Date informal complaint was filed with EVCC (if any):

Name and Title of person at EVCC who handled the informal complaint (if known, or UNKNOWN):

The issue, dispute, or incident involves disability discrimination under section 504 of the American with Disabilities Act and occurred within 30 calendar days of the date of this grievance.

Disability Information (Disclosure of diagnosis is voluntary and not required to file a grievance)

Do you have a documented disability under Section 504 / ADA?

Type of Disability (Optional)

Indicate the approximate date and/or timeframe of the incident(s) or actions that led to this complaint*:

Please describe each alleged discriminatory act. For each action, please include the date(s) the discriminatory act occurred, the name(s) of each person(s) involved and why you believe the discrimination was because of disability. Also provide the names of any person(s) who witnessed the act(s) of discrimination*.

Requested Resolution*

State the corrective action or remedy you are seeking. (Examples include implementation of accommodations, academic remedies, cessation of discriminatory conduct, training, policy modification, or other appropriate relief.)

Status of complaint: