N.J.A.C. 4A:1-5.7 Grievance form
N.J.A.C. 4A:1-5.7, Grievance form. following form may be utilized for the submission of a grievance pursuant to this subchapter: Americans with Disabilities Act Grievance Form Date: ......... Full text with cited by 1 other rule.
Current through New Jersey Register, Vol. 58 No. 14, July 20, 2026. Reviewed as of July 26, 2026.
This is an annotated mirror, not the official publication. Verify against the Civil Service Commission before relying on it.
In plain language
The form is printed in full inside the rule, and using it is optional, since 4A:1-5.6 requires the information rather than the format. Beyond the identifying fields it asks which department, division, bureau or office is alleged to have denied access, and where. Then the incident or barrier itself: what benefit, service, program or activity was denied or what discrimination occurred, with dates, times and places, the names or positions of any agency employees involved, and names, addresses and telephone numbers of witnesses. The last field is optional and easy to skip. Headed proposed access or accommodation and prefaced with if you wish, it invites a description of what would actually resolve the problem. Copies come from the coordinator named at 4A:1-5.4.
Written by the NJ Civil Service Navigator editorial team from the text of N.J.A.C. 4A:1-5.7. It is a description of the rule, not the rule itself, and not legal advice.
The following form may be utilized for the submission of a grievance pursuant to this subchapter:
Americans with Disabilities Act Grievance Form
Date: ..........
Name of grievant:
Address of grievant:
Telephone number of grievant:
Name, address and telephone number
of alternate contact person:
Agency alleged to have denied access:
Bureau or office:
Incident or barrier:
Please describe the particular way in which you believe you have been denied the benefits of any service, program or activity or have otherwise been subject to discrimination. Please specify dates, times and places of incidents, and names and/or positions of agency employees involved, if any, as well as names, addresses and telephone numbers of any witnesses to any such incident. Attach additional pages if necessary.
Proposed access or accommodation:
If you wish, describe the way in which you feel access may be had to the benefits described above, or that accommodation could be provided to allow access.
A copy of the above form may be obtained by contacting the designated ADA coordinator identified at N.J.A.C. 4A:1-5.4.