Section 504 Discrimination Complaint Form
Please complete the Section 504 Discrimination Complaint Form to report an incident. Provide as much detail as possible to help us review your complaint efficiently.
Your Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Contact
Email
Phone
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Incident
Person(s) or Entity Involved
Describe the Discriminatory Action or Event
*
Have you reported this incident to anyone else?
No
Yes (please specify below)
Additional Comments or Details (Optional)
Submit Complaint
Should be Empty: