ࡱ> U@ &zbjbj P$****lF+=z&,\....]/80Q1`<<<<<<<$(?RzAL<5]/]/55<..h=7775..<75<77758]8., H\*7M8u9L~=0=U8A7A]8A]81_2|72d?3111<<D7 CAJ-534 08/06 Title II of the Americans with Disabilities Act Complaint FormInstructions: Please fill out this form completely, in black ink or type. Sign and return to the address below.Complainant: FORMTEXT      Address: FORMTEXT      City, State and Zip Code: FORMTEXT      Telephone: Home: FORMTEXT      Business: FORMTEXT      Person Making the Complaint: FORMTEXT      (if other than the complainant)Address: FORMTEXT      City, State and Zip Code: FORMTEXT      Telephone: Home: FORMTEXT      Business: FORMTEXT      Department/Agency which your complaint is against:Name: FORMTEXT      Address: FORMTEXT      City, State and Zip Code: FORMTEXT      County: FORMTEXT      Telephone Number: FORMTEXT      1.) When did the event occur? Date: FORMTEXT      2.) Describe in detail the event providing the name(s) where possible for the individuals who were involved (use the bottom of page two if necessary): FORMTEXT       FORMTEXT       FORMTEXT       3.) My disability is  FORMCHECKBOX  Mental Characteristic  FORMCHECKBOX  Physical Characteristic (check as appropriate)4.) Describe the functional limitations caused by your disability for which you are requesting an accommodation. (Attach medical documentation.) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       CAJ-534 08/06 Page 2 5.) Describe any accommodations that you believe would minimize or eliminate the barriers for your participation in the specific program, activity or service provided by the Department. FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Signature:  FORMTEXT      Date:  FORMTEXT      (or signature of representative) Return to: Ms. Joanne M. Bridgford Equal Opportunity Administrator Michigan Department of Corrections P.O. Box 30003 Lansing, MI 48909 (Please keep a copy of this complaint for your records. Continued from previous page: 2.) (cont d.)  FORMTEXT       Department of Corrections ADA Title II Public Complaint Procedure Step 1: Complaint Fill out all of the information requested on the ADA Title II Complaint Form (CAJ-534). Mail or hand deliver the completed form to the ADA Coordinator for the Department of Corrections. If you need a reasonable accommodation to communicate your complaint, such as an interpreter or an alternative format, list this on your complaint form so that the ADA Coordinator will be able to effectively communicate with you at your meeting. 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Step 2: Meet With the ADA Coordinator Within 10 business days after your complaint is received by the ADA Coordinator, the Coordinator, or designee, will meet with you or contact you regarding your complaint. If it is determined that you are a qualified individual with a disability under the ADA, the Department will attempt to resolve the complaint. Step 3: Resolution of Your Complaint (A) Complaint Resolved: If you and the ADA Coordinator jointly agree to resolution of your complaint, the ADA Coordinator will put the joint agreement in writing and send it to you. The agreement will generally contain the following items: (1) A description of your complaint (2) A summary of the facts (3) A description of the resolution agreed to (4) The timeframe for resolving your complaint (5) An assurance that the MDOC will comply with the specific terms of the agreement. For this resolution to be effective, you must sign a copy of this agreement and return it to the ADA Coordinator in the time specified. (B) Complaint Not Resolved: If you and the ADA Coordinator cannot resolve your complaint, the ADA Coordinator will send you a notice of that fact. The notice will generally include the following: (1) A description of your complaint (2) A summary of any resolution proposed (3) A statement addressing the issues that could not be resolved. It is important to keep copies of the original complaint, notifications received after meeting with the Department, as well as any other correspondence or other documentation that is related to your complaint and bring those copies to all meetings, reviews, and appeals related to your complaint. If your complaint is not resolved, you may request a further review of your complaint by the Michigan Department of Civil Rights. You should file a request with the Department of Civil Rights within 10 business days after you receive your notice of non-resolution from the Department of Corrections ADA Coordinator. Send a copy of your original complaint and the Corrections non-resolution notice to the Department of Civil Rights. Please note that the Department of Civil Rights should be contacted for specific information regarding their review process. ooppHrrrrstsuu$z&z$$$$$$$$$$gdgd! 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