Student Background Information I verify that I have completed steps 1 and 2 of the informal process and want to appeal the proposed resolution. Confirm Name CIN Email Phone Permanent Address Student Status Undergraduate Graduate Complaint Details Type of complaint Denial of disability-related accommodation Other If other, please specify: Date of most recent incident Respondent(s) Person(s) who allegedly violated your ADA rights (include name, title and phone number): 1. Name Title Department Phone number 2. Name Title Department Phone number 3. Name Title Department Phone number Witness(es) (please include person's name, title, department and phone number): 1. Name Title Department Phone number 2. Name Title Department Phone number 3. Name Title Department Phone number Summary of Complaint. Please describe your concern with as much detail as possible. (Who, what, when, where and how. Include phone numbers and addresses, if possible) History. What step have been taken to remedy the situation? Who has been contacted, and when? Proposed action or resolution. * I am aware that a copy of this complaint may be forwarded to the instructor, department chair and the Office of the Dean of Students, if and when necessary. Confirm CAPTCHA