Grievance and Appeal Form

* = required field

Use this form if you would like to file a grievance or an appeal of your accommodations or accommodation request.

Today's Date*

/ /

First Name*

Last Name*

Luther Email Address*

This appeal or grievance is related to the following:*

Were you registered with Disability Services during the term the incident(s) occurred?*

	Yes
	No

Did you attempt to informally resolve the concern before filing a grievance or appeal?*

	Yes
	No

Please provide a complete description of your grievance or appeal. Provide all relevant details when possible (date and time, persons involved, persons who observed the incident, description or concern).

Please describe your efforts to informally resolve the concern.

Tarbabypre

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Tarbaby

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Noturl

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Antlion

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	Academic Accommodations
	Dining Accommodations
	Housing Accommodations
	Physical Education Requirement
	Campus Employment
	Other