I verify that I have informed my OSD counselor and or director about the issue contained on this form. Confirm Student Background Information Name CIN Email Phone number Permanent Address Student Status Undergraduate Graduate Complaint Details Type of complaint Denial of disability-related accomodation Other If other, please specify: Date of most recent incident Respondent(s) Person(s) who allegedly violated your ADA rights (include name, title, department and phone number): 1. Name Title Department Phone number 2. Name Title Department Phone number 3. Name Title Department Phone number Witness(es) (please include person's name, title, department and phone number): 1. Name Title Department Phone number 2. Name Title Department Phone number 3. Name Title Department Phone number Summary of complaint. Please describe your concern with as much detail as possible. (Who, what, when, where and how. Include phone numbers and addresses, if possible) History. What steps have been taken to remedy the situation? Who has been contacted, and when? Proposed action or resolution * I am aware that a copy of this complaint may be forwarded to the instructor, department chair and the Office of the Dean of Students if and when necessary. Confirm CAPTCHA