Appendix E: Sample Discrimination Complaint Form

(Reprinted with permission from Amicus, November 1977. Amicus is a publication of the National Center for Law and the Handicapped.)

1. Complainant:
   ________________________________________________________________

   Address:
   ________________________________________________________________

   Telephone:
   ________________________________________________________________

   Number of Employees:
   ________________________________________________________________

2. Which of the following best describes the disabling situation of the person discriminated against?

    

   1. Individual has a physical or mental impairment which substantially limits one or more major life activities.
   2. Individual has a record of such an impairment.
   3. Individual is regarded as having such an impairment.
3. Description of the nature of the disability:
   ________________________________________________________________
4. Person(s) discriminated against:
   ________________________________________________________________

   Address:
   ________________________________________________________________

   Telephone:
   ________________________________________________________________

5. Person(s) who committed discriminatory act:
   ________________________________________________________________

   Address:
   ________________________________________________________________

6. Nature of discriminatory act(s):
   ________________________________________________________________
7. Date(s) discrimination occurred:
   ________________________________________________________________
8. Additional background information:
   ________________________________________________________________
9. Additional person(s) harmed by discriminatory act(s):
   ________________________________________________________________
10. Witness to the discriminatory act(s):
    ________________________________________________________________
11. Attempted resolution of complaint to date:

     

    1. Complaint filed with other state or federal agency:

       ___yes ___no

       If "yes," name of agency:
       ______________________________________________

       Date filed:
       ______________________________________________

       Status of complaint:
       ______________________________________________

    2. Internal grievance procedure of institution:

       ___yes ___no

       Status of complaint:
       ______________________________________________

12. Person(s) to be contacted for further information with regard to complaint:

    Name: ______________________________________________________________

    Address: ____________________________________________________________

    Telephone:___________________________________________________________

Please find attached to this complaint copies of relevant correspondence with recipient institution or individual representatives concerning this matter.

I certify that the information given above is true and correct to the best of my knowledge or belief. (A willful false statement is punishable by law: U.S. Code, Title 18, Section 1001.)

_______________________________________

Signature