Code of Maine Rules › 12 - DEPARTMENT OF LABOR › 168 - DEPARTMENT OF LABOR - GENERAL › Chapter 50 - NONDISCRIMINATION POLICY AND GRIEVANCE PROCEDURE › Attachment 1 - STATE OF MAINE DISABILITY DISCRIMINATION GRIEVANCE REGARDING PROGRAMS, SERVICES, ACTIVITIES

Current through 2024-29, July 17, 2024
Procedures for filing a grievance are described in State of
				  Maine's "Non-Discrimination Policy and Grievance Procedure." While we encourage
				  you to use this grievance process, you also should be aware that the Maine
				  Human Rights Commission is another avenue for investigating cases that are
				  within its jurisdiction. You must file a complaint with that office no later
				  than 180 days after the alleged discriminatory action. (If your grievance is
				  resolved, you may withdraw your Commission complaint.) Call the Commission at
				  (207) 624-6050 (voice) or (888) 577-6690 (TTY) with any questions concerning
				  their process.
Please tell us if you need assistance in preparing this form,
				  or if you need to submit your grievance in a different format.
Please fill in the following sections. Be specific and
				  provide details to explain exactly what happened or what you are requesting.
				  Feel free to attach additional pages if you need more room.
Name:
				  ____________________________________________________
Address:
				  ____________________________________________________
Contact Number(s) (telephone, TTY, pager):
				  ______________________
______________________
What is the State program, service, or activity that is the
				  subject of your grievance or your request (for example, participating in a
				  program or attending a public meeting)"
________________________________________________________________________
Describe what happened (date, time, place, people involved,
				  and why you believe the incident was discriminatory):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What actions have you already taken to try to resolve this
				  grievance"
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
How would you like the State to resolve your grievance so
				  that you may participate in the program, service, or activity without
				  discrimination" Please list any alternatives, and let us know which you prefer.
				  Potential solutions could include changes to policies, practices, or
				  procedures; removing architectural, communication, or transportation barriers;
				  and providing auxiliary aids and services.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please be advised that, in order to evaluate this grievance,
				  the State may need to inquire as to the nature of your disability. If this
				  information is provided to the State, it will be maintained in a confidential
				  manner.
Please sign and date this form:
___________________________________________________
				  ____________________
Signature Date
Please give this form to the State employee running the
				  program
, or you may send it to: State Accessibility Coordinator, 150
				  State House Station, Augusta, ME 04333-0150.
Phone: (207) 623-7950 (voice), (888) 577-6690 (TTY), Fax:
				  (207) 287-5292.
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For State employee use
				  only:
Received by: _______________________________________________
				  Date: _____________________