Fill and Sign the Ada Accessibilitynebraska State Patrol Form

NEBRASKA JUDICIAL BRANCH Americans with Disabilities Act (ADA) Grievance Form 1. Name: ______________________________________________________________ Address: ____________________________________________________________ City: _______________________ State: _____________ ZIP code: _____________ Home Phone: ____________________ Cell Phone: __________________________ E-mail address: _______________________________________________________ 2. Date the alleged discriminatory act or decision occurred: _______________________ 3. Court/Probation location and name of the court/probation program or service involved that is the subject of this grievance. Court/Probation location: ________________________________________________ Name of program or service: ______________________________________________ 4. Type of accommodation requested: ___________________________________________________________________________ ___________________________________________________________________________ 5. Describe the alleged discriminatory act or decision (please be specific): ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ I certify that the above information is accurate ________________________________________ Signature of Grievant AD 2:18 Rev. 06/19 (required) ________________________________ Date signed Please submit or copy and mail the completed grievance form to: ADA Coordinator Amy Prenda State Capitol, Room 1213 Submit Lincoln, NE 68509 Phone: 402-471-2921 amy.prenda@nebraska.gov