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<br /> <br /> 30 <br />I. Grievance Form <br /> <br />Elk River <br />Title II of the Americans with Disabilities Act <br />Section 504 of the Rehabilitation Act of 1973 <br />Discrimination Complaint Form <br />Instructions: Please fill out this form completely, in black ink or type. Sign and return to the ADA coordinator whose contact <br />information is found in Appendix E. <br /> <br />Complainant Name: <br />Address: <br />City, State and Zip Code: <br />Telephone (Home): <br />Telephone (Business): <br />Person Discriminated Against: <br />(if other than the complainant) <br />Address: <br />City, State, and Zip Code: <br />Telephone (Home/Business or Both): <br /> <br />Government, or organization, or institution which you believe has discriminated: <br />Name: <br />Address: <br />County: <br />City: <br />State and Zip Code: <br />Telephone Number: <br />When was the issue discovered/when did the problem occur? (Date): <br />Describe the issue in detail, providing the name(s) where possible of the individuals who have <br />been contacted. (Add additional pages if necessary): <br />Have prior efforts been made to resolve this complaint through the Elk River grievance <br />procedure? <br />Yes______ No______ <br />If Yes: what is the status of the grievance? <br /> <br />Has the complaint been filed with another bureau of the Department of Justice or any other <br />Federal, State, or local civil rights agency or court? <br />Yes______ No______ <br />If Yes: Agency or Court: <br />Contact Person: <br />Address: <br />City, State, and Zip Code: <br />Telephone Number: <br />Date Filed: <br />Do you intend to file with another agency or court? <br />Yes______ No______