NCSEAA ADA Complaint Form

NCSEAA ADA Complaint Form

Please complete the form to the best of your ability. By completing this form, you can provide the details we need to undersand what happened. Required fields will be highlighted with a red *. If you are unable to complete the form, please contact ADA@ncseaa.edu or call 919-246-1813 to speak to the ADA Coordinator.

Last Name*

First Name*

Middle Name

Address Line 1*

Address Line 2

City*

State*

Zip Code*

Phone Number (Preferred)*

Phone

Email Address*

Date of Incident

Incident Description*

What is the primary reason for filing the ADA Complaint Form? Please describe the alleged discriminatory incident you experienced or witnessed in you own words. Please share details such as the date of time of the incident, the names of people involved in the incident, and any supporting details.

Have you submitted this complaint prior? *

Select or enter value

Details of Prior Complaint (Optional)

If you answered "Yes" to the question above, please describe when and to whom the initial complaint was submitted.

Additional Information

Is there any additional information you believe is relevant to this complaint?

Supporting Documents

Upload any additional information that you believe will be helpful.

**Please do not include any personal identifying information including social security numbers, birth date, or any other sensitive information not included on this form.**

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