ADA Grievance Form

ADA Grievance Form Instructions:

If you believe that a program or service is inaccessible to persons with a disability or is otherwise illegally discriminatory you may file a grievance with NEFA using this form.

To request an alternate format to file your grievance, please contact Jane Preston, NEFA’s accessibility coordinator, at jpreston@nefa.org or 617-865-1835.

To begin, please provide your contact information:

Your Name

Company

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Are you filing a grievance for yourself or on someone's behalf?

For myself

On behalf of another individual

Name

Company

Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Please indicate which type of program/service you are filing a grievance about:

Programs or services provided by NEFA

Programs or services that are not provided by, but are funded by, NEFA

Please provide the name and address of the business, organization, institution, or person that you believe has committed the discrimination.

Please describe the act of discrimination, the date or dates of occurrence, the location, the names of individuals involved, and the remedy or relief sought.

Have efforts been made to resolve this complaint between the individuals involved? If yes, please explain.

Have efforts been made to resolve this complaint either between the individuals involved or through the internal grievance procedure of the government, organization, institution, or business? If yes, please explain.

Upload relevant documentation.

One file only.
100 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

Please let us know if you want written communications in a specific format (e.g., large print, Braille, electronic documents) or require communications by video phone or TTY:

I agree to NEFA's Privacy Policy and Terms & Conditions of Use.

To submit, you must agree to our Privacy Policy and Terms & Conditions of Use, which govern how we collect, store, and use your information.

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