New Jersey Administrative Code
Title 5A - MILITARY AND VETERANS' AFFAIRS
Chapter 7 - DISABILITY DISCRIMINATION GRIEVANCE PROCEDURE
Subchapter 4 - ADA GRIEVANCE PROCEDURE
Section 5A:7-4.3 - Grievance form
Universal Citation: NJ Admin Code 5A:7-4.3
Current through Register Vol. 56, No. 6, March 18, 2024
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: ............ |
| ............................................................................. |
| 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. |
| ............................................................................. |
| ............................................................................. |
| ............................................................................. |
| ............................................................................. |
| ............................................................................. |
| ............................................................................. |
| 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. |
| ............................................................................. |
| ............................................................................. |
| ............................................................................. |
| A copy of the above form may be obtained by contacting the designated ADA |
| coordinator identified at 5A:7-3.1. |
Disclaimer: These regulations may not be the most recent version. New Jersey may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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