Formal Student Complaint Form for Denial of ADA Accommodations

Student Background Information
I verify that I have completed steps 1 and 2 of the informal process and want to appeal the proposed resolution.
Student Status
Complaint Details
Type of complaint
Respondent(s) Person(s) who allegedly violated your ADA rights (include name, title and phone number):
Witness(es) (please include person's name, title, department and phone number):
* 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.