New Jersey Administrative Code
Title 12A - COMMERCE
Chapter 1 - DISABILITY DISCRIMINATION GRIEVANCE PROCEDURE
Subchapter 4 - ADA GRIEVANCE PROCEDURE
Section 12A:1-4.3 - Grievance form

The following form may be utilized for the submission of a grievance pursuant to this subchapter:

Americans with Disabilities Act Grievance Form

Date: .........

Name of grievant: .........................................................

Address of grievant: ......................................................

Telephone number of grievant:..............................................

Name, address and telephone number of alternate contact

person: .....................................................................

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Agency alleged to have denied access:

Department: .................................................................

Division: ...................................................................

Bureau or office: ...........................................................

Location:....................................................................

Incident or barrier: ........................................................

Please describe the particular way in which you believe you have been denied the benefits of any service, program or activity or have otherwise been subject to discrimination. Please specify dates, times and places of incidents, and names and/or positions of agency employees involved, if any, as well as names, addresses and telephone numbers of any witnesses to any such incident. Attach additional pages if necessary.

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Proposed access or accommodation:

If you wish, describe the way in which you feel access may be had to the benefits described above, or that accommodation could be provided to allow access.

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A copy of the above form may be obtained by contacting the designated ADA coordinator identified at 12A:1-3.1.