{Insert Name of Program}

Americans with Disabilities Act

SIGNATURE SHEET

 

 

 

By signing below, I acknowledge that I have either read or had explained to me the Notice Under the Americans with Disabilities Act and the Grievance Procedure.

 

I understand that I may have a copy of the Notice under the Americans with Disabilities Act if I want one.

 

I understand that if I have questions, concerns or complaints I should contact the {Insert Name of Person coordinating ADA complaints}, at {Insert telephone number}.

 

 

 

Signature of Service Recipient

 

 

 

Print Name of Service Recipient

 

 

 

Date

 

 

________________________________________________

Witness

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insert Name of Agency}

NOTICE UNDER THE AMERICANS WITH DISABILITIES ACT

 

This Notice is provided to you as required by Title II of the Americans with Disabilities Act of 1990. 

 

Program Services:  The {insert name of agency} does not prevent individuals on the basis of a disability admission and participation in its services, programs, or activities. {Insert name of agency} will make all reasonable modifications to programs to help participation by persons with disabilities.  The ADA does not require {insert name of agency} to make modifications, if the nature of the program was changed or created an undue financial or administrative burden.

 

Employment: {Insert name of agency} does not discriminate on the basis of disability in its hiring or employment practices.

 

Communication:  {Insert name of agency} will for most requests provide the aids and services for individuals to communicate to participate as everyone else in the programs, services, and activities.  If you need help through aids or services in the area of communication to participate in programs of {insert name of agency}, should contact {insert name and contact information for ADA Coordinator}.

 

Question, concerns, complaints, or requests for more information regarding the ADA may be forwarded to {insert name of agency} designated ADA Coordinator.

 

Name:  ______________________________________________________

 

Title:  _______________________________________________________

 

Office Address:  _______________________________________________

 

                            _______________________________________________

 

Phone Number:  ___________________

 

This Notice is available upon request in large print, audio tape and Braille formats.

 

 

 

 

 

 

 

The above document represents information from the following web site:  Department of Justice, ADA Best Practices Tool Kit for State and Local Governments, http://www.ada.gov/pcatoolkit

 

{Name of Agency}

The Grievance Procedure

 

  • A grievance is a written method for making a complaint.

 

  • If you think you have been discriminated against in an adult literacy program because of your disability, you may:

 

1.      Clear up your complaint by talking with the people involved;

 

2.      File a formal grievance with the program; and/or

 

3.      File your complaint directly with the U. S. Department of Education, Office of Civil Rights.

 

·       A program cannot treat you differently or retaliate against you for filing a complaint.  If you feel that the program is treating you differently or treating you badly because you have filed a complaint, report it to the U. S. Department of Education, Office of Civil Rights immediately.

 

 

 

 

 

 

 

 

 

 

 

 

 

The material above is part of the document available on the web for printing at: http://das.kucrl.org/iam.html .  The document was supported in whole or in part by the U.S. Department of Education, Office of Special Education Programs, (Cooperative Agreement No. H324M980109).

{Name of Agency}

Grievance Procedure under

The Americans with Disabilities Act

 

 

The {Insert Name of Program} has adopted this grievance procedure for an individual to file a complaint that the program did not follow Title II of the Americans with Disabilities Act.  Title II of the ADA states in part that…no otherwise qualified disabled individual shall, solely by reason of such disability, be excluded from the participation in, be denied the benefits for, or be subjected to discrimination… in programs or activities sponsored by a public entity”. This procedure meets the requirements of the Americans with Disabilities Act of 1990 (“ADA”).  

 

The {Insert name of Agency}’s Personnel Policy governs employment-related complaints of disability discrimination.

 

·                  A complaint may be filed by you or someone you have asked to act on your behalf.

 

·                  The complaint should be in writing and contain:

 

§         Your name, address, and phone number

§         The name and location of the program that you believe discriminated against you

§         A detailed description of what happened and when it happened

§         The reason for the violation of the ADA that is, you are a person with a disability.

 

·                  Alternative means of filing complaints, such as personal interviews or a tape recording of the complaint will be made available upon request.

 

·                  A complaint should be submitted no later than 60 calendar days after the alleged violation occurred to the person named below who has been designated to coordinate ADA compliance efforts:

 

Name:___________________________________________

 

Address:_________________________________________

 

_________________________________________________

 

Phone Number:____________________________________

 

 

·                   Within 15 calendar days a complaint is received, {Insert Name Referenced Above} will meet with the complainant to discuss the complaint and the possible resolutions. 

·                   A data gathering process shall follow the filing of a complaint where all interested persons and/or their representatives, if any, have an opportunity to submit information relevant to the complaint. 

 

·                   Within 15 calendar days after the meeting, {Insert Name Referenced Above} will respond in writing, and where appropriate, in a format accessible to the complainant, such as large print, Braille, or audio tape.  The response will explain the position of the {name of agency} and offer options to substantive resolution of the complaint.

 

·                   This process shall be conducted by {Insert Name Referenced Above} or in (his/her) absence, any other person designated by the program or agency director.

 

·                   If the response by {Insert Name Referenced Above} or {his/her} designee does not satisfactorily resolve the issue, the complainant may appeal the decision within 15 calendar days after receipt of the response to the {Insert Name of next appropriate high level official}.

 

·                   The above process and time limits for handling a complaint, i.e. meet with the complainant to discuss the complaint and possible resolutions, information gathering and providing a written or appropriate alternative format response with a final resolution of the complaint shall occur at the next higher level of review.

 

·                   The {Insert Name Referenced Above} shall maintain the files and records of {Insert Name of Program} all written complaints sent to the program and appeals to other offices.  These records will be retained for at least three years.

 

·               A program cannot treat you differently or retaliate against you for filing a complaint.  If you feel that the program is treating you differently or treating you badly because you have filed a complaint, report it to the U. S. Department of Education, Office of Civil Rights immediately.

 

·                 Complaints to the U. S. Department of Education, Office of Civil Rights must be filed within 180 days of discrimination or within 60 days after the program/agency has provided communication to you regarding resolution of your complaint.

 

U.S. Department of Education

Office of Civil Rights

400 Maryland Avenue, S. W.

Washington, D.C.   20202-1100

1-800-421-3481

Web: http://www.ed.gov/ocr

E-mail: OCR@ed.gov

 

 

 

·                 To file a formal complaint with the U. S. Department of Education, Office for Civil Rights (OCR) you should submit in writing the following information:

      • Your name, address, and phone number
      • The name and location of the program that you believe discriminated against you
      • A detailed description of what happened and when it happened
      • The reason for the violation of the ADA that is, you are a person with a disability.

 

·               Make sure enough detail is provided for the Office of Civil Rights to know what happened.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The above document represents a synthesis of information from the following web sites:  Department of Justice, Title II of the Americans with Disabilities Act, www.ada.gov/reg2;

Department of Justice, ADA Best Practices Tool Kit for State and Local Governments, http://www.ada.gov/pcatoolkit.  Acknowledgement is also given to the Arkansas Adult Education and Literacy, Policy & Procedure Manual for Serving Students with Learning Disabilities and/or Attention Deficit Hyperactivity Disorder, http://aalrc.org/resources/ld/policyManual/index.aspx.