Appendix E: Sample Discrimination Complaint Form

Table of Contents

(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

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