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Americans With Disabilities Act Grievace Form CC-DC 50 - Maryland
| Americans With Disabilities Act Grievace Form Form. This is a Maryland form and can be used in General District Court Statewide . |
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State of Maryland Judiciary Americans with Disabilities Act Grievance Form Name: Address: Telephone No. TTY/TTD Case No. Nature of disability: Alternative contact person: Name Address Telephone No. TTY/TTD Which Court/Agency you believed denied access. (Please attach a copy of any denial of request for accommodation.): Court/Unit: Location: Describe your grievance. Please specify dates, times, or incidents, and names or positions of Judiciary employees involved, if any, as well as names, addresses, and telephone numbers of any witnesses to any such incident. Attach additional pages if necessary. What would you like to see happen? I request that this information be kept confidential to the extent allowed by law. This form should be submitted to the ADA Coordinator in the jurisdiction where the complaint originated. If you need assistance in completing this form, please contact the ADA Coordinator. I certify that to the best of my knowledge this information is true and correct. Type or Print Name Date Signature You have the right to appeal the decision to the Office of Fair Practices. The appeal must be received or postmarked within 15 days after the complainant received the response. Office of Fair Practices 2001 C Commerce Park Drive Annapolis, Maryland 21401 Fax: 410-260-3575 CC-DC 50 (Rev. 10/2011) American LegalNet, Inc. www.FormsWorkFlow.com
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