Form AD2:18 "Americans With Disabilities Act (Ada) Grievance Form" - Nebraska

What Is Form AD2:18?

This is a legal form that was released by the Nebraska Judicial Branch - a government authority operating within Nebraska. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2018;
  • The latest edition provided by the Nebraska Judicial Branch;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form AD2:18 by clicking the link below or browse more documents and templates provided by the Nebraska Judicial Branch.

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Download Form AD2:18 "Americans With Disabilities Act (Ada) Grievance Form" - Nebraska

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NEBRASKA JUDICIAL BRANCH
Americans with disabilities Act (ADA) Grievance Form
1. Name: ______________________________________________________________
Address: ____________________________________________________________
City: _______________________ State: _____________ ZIP code: _____________
Home Phone: ____________________ Cell Phone: __________________________
E-mail address: _______________________________________________________
2. Date the alleged discriminatory act or decision occurred: _______________________
3. Court/Probation location and name of the court/probation program or service involved that is the
subject of this grievance.
Court/Probation location: ________________________________________________
Name of program or service: ______________________________________________
4. Type of accommodation requested:
___________________________________________________________________________
___________________________________________________________________________
5. Describe the alleged discriminatory act or decision (please be specific):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
I certify that the above information is accurate
(required)
________________________________________
________________________________
Signature of Grievant
Date signed
Please submit or copy and mail the completed grievance form to:
ADA Coordinator
Judy Beutler
State Capitol, Room 1213
Submit
Lincoln, NE 68509
Phone: 402-471-2921
judy.beutler@nebraska.gov
AD 2:18 New 08/18
NEBRASKA JUDICIAL BRANCH
Americans with disabilities Act (ADA) Grievance Form
1. Name: ______________________________________________________________
Address: ____________________________________________________________
City: _______________________ State: _____________ ZIP code: _____________
Home Phone: ____________________ Cell Phone: __________________________
E-mail address: _______________________________________________________
2. Date the alleged discriminatory act or decision occurred: _______________________
3. Court/Probation location and name of the court/probation program or service involved that is the
subject of this grievance.
Court/Probation location: ________________________________________________
Name of program or service: ______________________________________________
4. Type of accommodation requested:
___________________________________________________________________________
___________________________________________________________________________
5. Describe the alleged discriminatory act or decision (please be specific):
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
I certify that the above information is accurate
(required)
________________________________________
________________________________
Signature of Grievant
Date signed
Please submit or copy and mail the completed grievance form to:
ADA Coordinator
Judy Beutler
State Capitol, Room 1213
Submit
Lincoln, NE 68509
Phone: 402-471-2921
judy.beutler@nebraska.gov
AD 2:18 New 08/18