Discrimination Based on Disability Formal Grievance Procedure Form

The complainant is encouraged although not required to first proceed with informal resolutions. The informal resolution procedure can be found by clicking HERE.

The college's Affirmative Action Officer and Title IX Coordinator is Kim Evans-Dame Director of Human Resources, Room 113 of the Academic Building, Utica Campus, telephone is 315-792-5637. Coordinator of Disability Services, and Section 504/ADA Coordinator is Tamara Mariotti, Room 153 of the Academic Building, Utica Campus, telephone 315-731-5702 (Voice).


Complainant's First Name:


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Complainant's Last Name:


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M #:


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E-mail:

@student.mvcc.edu
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Mailing address:


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City:


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State:


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ZIP:


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Telephone Number:


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Names and Telephone Numbers of any witnesses (if applicable):

Please describe what informal process steps you have undertaken:

A concise description of the act or omission (please include the date or dates of occurence): Please state all facts relevant to the alleged complaint:

Desired Remedy:

Please state all arguments in support of the desired solution:

Please attach any relevant documentation.

By typing my signature I affirm that the above information is true.

Signature (as name appears on Student ID):


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Date:


Form must be submitted no later than 45 calendar days after date of last occurence or within 5 business day following an unsuccessful informal resolution process.


Please click "Submit" button once ONLY