Formal Disability Discrimination Complaint Form

* indicates a required field

Response

This form should be used to report concerns regarding possible discrimination based on one's disability.

Once the form is received, the incident will be investigated, and the concern reported will be addressed. We strive to protect the reporter's confidentiality when possible. You may be contacted to provide additional information if needed. Please provide as much information as possible to assist with receiving a timely response.

First Name

Last Name

Phone Number

Physical Address

Nature of this report

Location of Incident

Date of Incident

Time of Incident

If you are registered with Disability Support Services, have you shared your concerns with you assigned coordinator?

What action/remedy are you seeking?

Involved Parties

Include any names of individuals who may have additional information or who may have been involved. Also, please identify each individual's role by listing them as a person of concern, victim, or witness, as applicable.

Description/Narrative

Please provide a concise and objective account of the details of the incident(s) and the behaviors observed. Indicate who, what, why, where, when and how statements to describe the situation. Also, indicate dates and times as appropriate.

Supporting Documentation

Feel free to provide any supporting documents that provide additional information, to include by not limited to: photos, videos, emails, etc.

Please send any supporting documents to the College's ADA Compliance Officer:

Angelita Ragland, MS, CRC
9101 Fayetteville Rod, Building A, Suite 138B
Raleigh, NC
P: 919.866.5733
F: 919.662.3616
amragland@waketech.edu