N.J. Admin. Code § 19:30-7.7

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Current through Register Vol. 56, No. 12, June 17, 2024

Section 19:30-7.7 - Complaint form

The following form may be utilized for the submission of a complaint pursuant to this subchapter:

Americans with Disabilities Act Complaint Form

Date: .........

Name of complainant:

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Address of complainant:

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Telephone number of complainant:

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Disability of complainant:

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Name, address and telephone number of alternate contact person (if applicable):

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Incident or barrier:

Please describe the particular way in which you believe you have been denied the benefits of any service, program or activity or have otherwise been subject to discrimination. Please specify dates, times and places of incidents, and names and/or positions of Authority employees involved, if any, as well as names, addresses and telephone numbers of any witnesses to any such incident.

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Proposed access or accommodation:

If you wish to describe the way in which you feel access may be had to the benefits described above, or what accommodation could be provided to allow access.

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A copy of the above form may be obtained by contacting the designated ADA coordinator identified at 19:30-7.4(a).

N.J. Admin. Code § 19:30-7.7