Illinois Administrative Code › Title 4 - DISCRIMINATION PROCEDURES › Part 1725 - AMERICANS WITH DISABILITIES ACT AND CIVIL RIGHTS PROGRAM GRIEVANCE PROCEDURE › Subpart B - PROCEDURES › Appendix A - ADA/Civil Rights Program Formal Grievance Intake Form

Current through Register Vol. 48, No. 28, July 12, 2024
ADA/Civil Rights Program Formal Grievance
				  Intake Form
Discrimination Based on a Disability
Denial of Reasonable Accommodation
				  Request
It is the policy of the Illinois Department on Aging to
				  provide assistance in filling out these forms. If assistance is needed, please
				  ask:
ADA/Civil Rights Program Coordinator
Illinois Department on Aging
421 East Capitol Avenue, #100
Springfield IL 62701-1789
217/785-3346 (Voice) or 888/206-1327
				  (TTY)
Contact Information
Name:________________________________________________________________
Address:______________________________________________________________
City, State and Zip
				  Code:__________________________________________________
Telephone No.: _____________ (Voice) _____________ (TTY) Fax
				  No. _____________
Best Means and Time for Contacting:
				  ________________________________________
Alleged Discrimination
Please fill out this part if you were excluded from
				  participation in, or denied the benefits of, any program, service, or activity
				  of the Department on the basis of a disability or have been subject to
				  discrimination by the Department under federal and State civil rights laws
				  based on classification characteristics such as age; ancestry, citizenship,
				  color, national origin or race; creed or religion; disability; familial status,
				  gender, sex, or sexual orientation; military status or unfavorable discharge
				  from military service; or retaliation for having opposed an unlawful practice.
				  A response must be provided for each line in order for the Department to take
				  action. You may attach additional sheets for your responses, if necessary. Do
				  not submit an incomplete form.
Program, Service, or Activity to which Access was Denied or
				  in which Alleged Discrimination
				  Occurred:___________________________________________________________________
Date of Alleged
				  Discrimination:_____________________________________________
Nature of Alleged
				  Discrimination:____________________________________________
(OVER)
(BACK OF FORM)
Reasonable Accommodation Requests
Please fill out this part if your reasonable accommodation
				  was denied. Reasonable accommodations could include such things as providing
				  auxiliary aids and devices and changing some policies and/or requirements to
				  allow a qualified individual with a disability to participate in any program,
				  service, or activity of the Department. You may attach additional sheets for
				  your responses, if necessary. A response should not be provided for any line
				  that you do not know the answer.
Exact Nature of
				  Disability:___________________________________________________
(Please attach a signed statement from a physician currently
				  licensed to practice in Illinois.)
Reasonable Accommodation
				  Requested:______________________________________
Date the Reasonable Accommodation was
				  Requested:____________________________
Person to whom the Request was
				  Made:_______________________________________
Reason for
				  Denial:________________________________________________________
Estimated Cost of Accommodation (if an assistive device, such
				  as a TTY or optical reader, or commodity or service for which a cost is readily
				  known):_____________________________
Why is the Requested Accommodation Necessary to Use or
				  Participate in the Program, Service, or
				  Activity?___________________________________________________________________
Alternative Accommodations that may Provide
				  Accessibility:________________________
Any Other Information You Believe Will Aid in a Fair
				  Resolution of this Grievance:___________
Signature
I certify that I am qualified or otherwise eligible to
				  participate in the program, service, or activity and the above statements are
				  true to the best of my knowledge and belief.
_________________________________
SignatureDate
Please return upon completion to the ADA/Civil Rights Program
				  Coordinator at the address listed at the top of the front page.
For Internal Use Only
Date Received:________________________
				  By:_________________________________