Appeal of Grievance Resolution (ADA/504)

Original Grievance Date

Date of alleged action:(Required):

This field is required.

Student Information

Please enter your information here. If you do not enter your information, your grievance will be received, but no additional action will be taken.

Full name

Student ID Number

Phone number

Email address (@email.vccs.edu)

Mailing Address

Type of Grievance or Complaint

Have you already submitted a Student Grievance ADA/504 Form, received a decision, and wish to appeal that decision?(Required)

Yes No

This field is required.

Check which concern(s) apply:(Required)

A requested service or accommodation, including appeals of determinations regarding accommodations Inaccessibility of a college program or activity Access of a service animal Harassment on the basis of disability in violation of college policy Any other alleged college violation of the ADA or the Rehabilitation Act Retaliation

You must make at least one selection.

If the concern is not listed in the above question - please describe below: This field is required.

Name of person(s) you believe discriminated against you:(Required) This field is required.

Class (if applicable). List N/A if this grievance does not apply to a class(Required) This field is required.

Semester and Year:(Required) This field is required.

Please provide a description of the situation:(Required) This field is required.

What action are you requesting to rectify your grievance following the resolution that has already been provided?(Required) This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Original Grievance Date

Student Information

Type of Grievance or Complaint

Supporting Documentation

Submission