Disability Law Center Grievance Form

1. Disability Law Center Grievance Form

When you have completed this form, please email a note to akpa@dlcak.org letting us know you've done so. Due to the limitations of this questionnaire software, we may not know that you have completed this form unless you send us an email.

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* 1. Please fill out the Contact information below so that we may respond to your concerns.

Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP/Postal Code: *

Email Address:

Phone Number:

Please complete all sections which apply to your concerns.

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* 2. Describe the type of help that you requested from the Disability Law Center.

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* 3. On what date did you receive the notice with which you disagree?

Decision Date:

Date

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* 4. I was told that the Disability Law Center (DLC) would not provide me services. I disagree with this decision because:

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* 5. I am unhappy with the services that I am receiving from DLC because:

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* 6. I disagree with the decision of DLC to limit services to me or to close my case because:

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* 7. I believe that DLC has treated me unfairly or has not carried out its legal obligations, because:

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* 8. I would like to make this additional statement:

The Disability Law Center (DLC) thanks you for the opportunity to address your concerns.

The Executive Director will issue a written determination within 15 working days of the filing of your grievance.
If you are dissatisfied with the written determination of the Executive Director, you may appeal the determination to the Grievance Committee of the DLC Board of Directors. This appeal must be returned to DLC within 30 calendar days following the decision of the Executive Director with which you disagree.
The appeal decision will be issued within 30 calendar days. The decision of the grievance committee is the final determination of the agency.

When you have completed this form, please email a note to akpa@dlcak.org letting us know you've done so.
Due to the limitations of this questionnaire software, we may not know that you have completed this form unless you send us an email.