Reasonable Accommodation Complaint Form | Pre-Major Advising

Answer any questions as completely as possible. If you do not know the answer to the question, please respond by stating “not known.” If the question is not applicable, please write “N/A.”

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Name

Address

Phone Number

Email Address

Check One

Student

Employee

Applicant

Department

What accommodation have you been offered? By whom? Date? *

Why is it not acceptable? *

What accommodation have you suggested? To whom? Date? *

Why is it more appropriate? *

Additional Comments

I, the undersigned, certify that this document is a complete and accurate statement of my complaint. I further understand that the information provided herein is not confidential and will be reviewed by the University personnel and employees to determine the existence of facts relevant to this complaint. I further understand that the information provided herein will be disclosed to the responding party and individuals identified herein as well as for routine use purposes at Radford University.

By signing this document, I consent to the review, processing, investigation, and disclosure of the enclosed information by the Office of Diversity and Equity as stated above. I will cooperate with the Office of Diversity and Equity's investigation and complaint resolution activities. I understand that my failure to cooperate with the Office of Diversity and Equity’s investigation may result in the closure of my complaint. I further verify that I have been provided with a copy of Radford University Discrimination Complaint Procedure.

Signature

Today's Date

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Radford University does not discriminate based on the basis of race, color, age, disability, National Origin, gender, sexual orientation, religion, pregnancy, Veteran’s status, political affiliation, or retaliation.