Discrimination Based on Disability Formal Grievance Procedure Form

The complainant is encouraged although not required to first proceed with informal resolutions. The informal resolution procedure can be found on Alleged Discrimination Based on Disability Informal Resolution Process.

The college's Affirmative Action Officer and Title IX Coordinator is Executive Director of Human Resources, Room 113 of the Academic Building, Utica Campus, telephone is 315-792-5637. Dean of Student Support and Section 504/ADA Coordinator is James Maio, PH127, Utica Campus, telephone 315-792-5401 (Voice).

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Complainant's First Name*

Complainant's Last Name*

M Number*

E-mail*

Mailing Address*

City*

State*

Zip Code*

Telephone Number*

Name and Phone of any witnesses (if applicable).

Describe what informal process steps you have taken.

A concise description of the act or omission. State all facts relevant to the complaint.*

Date of alleged act

Desired Remedy

State arguments in support of desired solution*

By typing my signature, I affirm that the above information is true.

Signature*

Date*

Form must be submitted no later than 45 calendar days after date of last occurence or within 5 business day following an unsuccessful informal resolution process.