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ADA Grievance Form

  1. Please fill out the form completely, sign the form, and submit within 60 days of any incident.

  2. Type of Grievance (select any that apply)*
  3. Complaint / Incident Details

  4. Have efforts been made to resolve this complaint through the Department in which the alleged discrimination took place?
  5. Contact Information

    Reporting Individual

  6. On Behalf of:

    (if different than Reporting Individual)

  7. For questions about this form, please contact ADA Coordinator Paul Rudacille at or call 434-970-3182

  8. Leave This Blank:

  9. This field is not part of the form submission.