Free Americans With Disabilities Act Grievance Form - Maryland

State of Maryland Judiciary Americans with Disabilities Act Grievance Form
Name: Address:
Telephone No. TTY/TTD

Case No. Nature of disability:

Alternative contact person:
Name Address Telephone No. TTY/TTD

Which Court/Agency you believed denied access. (Please attach a copy of any denial of request for accommodation.):

Court/Unit: Location: Describe your grievance. Please specify dates, times, or incidents, and names or positions of Judiciary employees involved, if any, as well as names, addresses, and telephone numbers of any witnesses to any such incident. Attach additional pages if necessary.

What would you like to see happen?

I request that this information be kept confidential to the extent allowed by law. This form should be submitted to the ADA Coordinator in the jurisdiction where the complaint originated. If you need assistance in completing this form, please contact the ADA Coordinator. I certify that to the best of my knowledge this information is true and correct.

Type or Print Name

Date

Signature

You have the right to appeal the decision to the Administrative Judge of the County District or Circuit Court or the Chief Judges of the appellate court where the grievance occurred. CC-DC 50 (Rev. 9/2005)