State of Michigan ADA Appeal Form

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<ul class="nav flex-column mt-1"> <li class="nav-item"> <a href="/disabilityresources/ada-complaint-procedure/ada-appeal-form" class="nav-link"> State of Michigan ADA Appeal Form </a> </li> <li class="nav-item"> <a href="/disabilityresources/ada-complaint-procedure/ada-complaint-form" class="nav-link mobile-lv2-last"> State of Michigan ADA Complaint Form </a> </li> </ul> </div> </div> </div> <div class="col-12 mobile-nav third-level" id="m_subnav_f931471467f44754b4fc02abc118682e"> <div class="row no-gutters"> <div class="col-12"> <a class="nav-link third-level-back not-active" href="#"><span class="header-caret-back"></span>Back</a> <a class="nav-link third-level-title h3 ml-1 text-primary d-block" href="/disabilityresources/ada-complaint-procedure/ada-appeal-form"> State of Michigan ADA Appeal Form </a> </div> </div> </div> <div class="col-12 mobile-nav third-level" id="m_subnav_a7fd2ce5bd804b7faf542db037530395"> <div class="row no-gutters"> <div class="col-12"> <a class="nav-link 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Please try again later.</p> </div> </div><div class="links-container px-0"> <div class="container"> <div class="row"> <div class="col-md-4"> <div class="search-links-container"> <h3>Available Forms</h3> <ul class="search-links-list"> <li class="search-links-item"><a class="search-links-link" href="/disabilityresources/ada-complaint-procedure/ada-complaint-form" target="_blank">State ADA Complaint Form</a></li> <li class="search-links-item"><a class="search-links-link" href="/disabilityresources/ada-complaint-procedure/ada-appeal-form" target="_blank">ada-appeal</a></li> </ul> </div> </div> <div class="col-md-4"> <div class="search-links-container"> <h3>How Do I...</h3> <ul class="search-links-list"> <li class="search-links-list"><a class="search-links-link" href="/disabilityresources/state-prog" target="_blank">View State Programs and Services</a></li> <li class="search-links-list"><a class="search-links-link" href="/disabilityresources/ada-notice/coordinators" target="_blank">ada-coordinator</a></li> </ul> </div> </div> </div> </div> </div></div> </div> </div> </div> </header>   <main> <div id="content" class=""> <div class="modal fade" id="browserDetectModal" tabindex="-1" role="dialog" aria-labelledby="browserDetectModalLabel" aria-hidden="true"> <div class="modal-dialog" role="document"> <div class="modal-content"> <div class="modal-header"> <button type="button" class="close modal-dialog-close" data-dismiss="modal" aria-label="Close"> <span><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 32 32" aria-label="close" data-tags="X dismiss deny denied ex" role="img" fill="currentColor" focusable="false"><path d="M24 9.4 22.6 8 16 14.6 9.4 8 8 9.4 14.6 16 8 22.6 9.4 24 16 17.4 22.6 24 24 22.6 17.4 16 24 9.4z" /></svg></span> </button> </div> <div class="modal-body"> <div class="modal-browser-detect-wrapper"> <div class="container"> <div class="row"> <div class="col-lg-2"> <span class="warning-icon"></span> </div> <div class="col-lg-8"> <div class="browser-detection-box__section-content"> <div class="browser-detection-box__section-heading">Unsupported Browser Detected</div> <p>The web Browser you are currently using is unsupported, and some features of this site may not work as intended. 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Are you unable to access a state program, service, or activity due to your disability? Use this form to report disability discrimination to the State of Michigan’s ADA Coordinators.</p> <p>If you wish to report your concerns of discrimination in another format, you may do so by contacting the state government entity’s ADA Coordinator directly using the <a href="/disabilityresources/ada-notice/coordinators">ADA Coordinator contact list</a>.</p> <p>More information on this complaint process can be found on the <a href="https://www.michigan.gov/disabilityresources/ada-complaint-procedure"class="off-domain-link">ADA Complaint Procedure webpage</a>.</p> <div> </div> <p><strong> </strong></p> <p><strong>Caution:</strong> Please remember to save and/or print your completed appeal form before using the Submit button.<br /> <br /> </p> <p> <strong>Note: </strong>When you use the Submit button the information is transmitted electronically to the State of Michigan department or agency selected, and at the same time the information is cleared from the form. </p> <p> Please use your browser's 'Save as' functionality to save a copy of your completed form for your records. </p> <p> Please use your browser's 'Print' functionality to print a copy of your completed form for your records and/or to mail your appeal if you wish to submit the appeal using the United States Postal Service.</p> </div> </div> </div> </div> </div> <div class="component sitecore-form"> <div class="component-content"> <div class="container"> <div class="row"> <div class="col-12"> <form action="/formbuilder?sc_site=disabilityresources&fxb.FormItemId=e1610256-adff-4e53-9a5b-be56cd161e9f&fxb.HtmlPrefix=fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f" data-ajax="true" data-ajax-method="Post" data-ajax-mode="replace-with" data-ajax-success="$.validator.unobtrusive.parse('#fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_e1610256-adff-4e53-9a5b-be56cd161e9f');$.fxbFormTracker.texts=$.fxbFormTracker.texts||{};$.fxbFormTracker.texts.expiredWebSession='Your session has expired. 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value="" maxlength="255" placeholder="" data-sc-tracking="True" data-sc-field-name="Email Address" data-sc-field-key="9C371DE99C4E496EB1A7AF9D5BDD45A2" data-val-regex="Email Address contains an invalid email address." data-val-regex-pattern="^[A-Za-z0-9._%+-]+@[A-Za-z0-9.-]+\.[A-Za-z]{2,17}$" data-val-required="Email Address is required." data-val="true"/> <span class="field-validation-valid" data-valmsg-for="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[fff61e7f-0570-45e1-bb57-0f7f4c03f3cf].Value" data-valmsg-replace="true"></span><input id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_Index_d2aec930-af48-41c7-b856-a38811be445b" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields.Index" type="hidden" value="d2aec930-af48-41c7-b856-a38811be445b" /><input id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_d2aec930-af48-41c7-b856-a38811be445b__ItemId" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[d2aec930-af48-41c7-b856-a38811be445b].ItemId" type="hidden" value="d2aec930-af48-41c7-b856-a38811be445b" /><label class="">Is this your first submittal of an appeal?</label> <label class=""> <input type="radio" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[d2aec930-af48-41c7-b856-a38811be445b].Value" value="Yes" data-sc-tracking="True" data-sc-field-name="Radio Button List" data-sc-field-key="7357B9BF07E54DDD80E720A06CC9F4AF" data-val-required="Is this your first submittal of an appeal? is required." data-val="true"/>Yes </label> <label class=""> <input type="radio" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[d2aec930-af48-41c7-b856-a38811be445b].Value" value="No" data-sc-tracking="True" data-sc-field-name="Radio Button List" data-sc-field-key="7357B9BF07E54DDD80E720A06CC9F4AF" />No </label> <span class="field-validation-valid" data-valmsg-for="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[d2aec930-af48-41c7-b856-a38811be445b].Value" data-valmsg-replace="true"></span><input id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_Index_5a1ef0f5-3b14-4391-a947-4cdbd3adc7fc" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields.Index" type="hidden" value="5a1ef0f5-3b14-4391-a947-4cdbd3adc7fc" /><input id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_5a1ef0f5-3b14-4391-a947-4cdbd3adc7fc__ItemId" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[5a1ef0f5-3b14-4391-a947-4cdbd3adc7fc].ItemId" type="hidden" value="5a1ef0f5-3b14-4391-a947-4cdbd3adc7fc" /><label for="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_5a1ef0f5-3b14-4391-a947-4cdbd3adc7fc__Value" class="">If No, where the appeal was filed and whether it was filed with a Federal, State, or Local Civil Rights Agency or Court. (optional)</label> <textarea id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_5a1ef0f5-3b14-4391-a947-4cdbd3adc7fc__Value" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[5a1ef0f5-3b14-4391-a947-4cdbd3adc7fc].Value" class="" rows="4" maxlength="512" placeholder="" data-sc-tracking="True" data-sc-field-name="If No where the appeal was filed and whether it was filed with a Federal State or Local Civil Rights" data-sc-field-key="3B651EB4C002401EBAE89144E7564A2B" ></textarea> <span class="field-validation-valid" data-valmsg-for="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[5a1ef0f5-3b14-4391-a947-4cdbd3adc7fc].Value" data-valmsg-replace="true"></span><input id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_Index_735de852-359c-42c7-a47d-87ba84fc5887" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields.Index" type="hidden" value="735de852-359c-42c7-a47d-87ba84fc5887" /><input id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_735de852-359c-42c7-a47d-87ba84fc5887__ItemId" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[735de852-359c-42c7-a47d-87ba84fc5887].ItemId" type="hidden" value="735de852-359c-42c7-a47d-87ba84fc5887" /><label for="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_735de852-359c-42c7-a47d-87ba84fc5887__Value" class="">Describe what the proposed Department or Agency resolution is and why it is not a satisfactory resolution to the discriminatory incident.</label> <textarea id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_735de852-359c-42c7-a47d-87ba84fc5887__Value" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[735de852-359c-42c7-a47d-87ba84fc5887].Value" class="" rows="4" maxlength="512" placeholder="" data-sc-tracking="True" data-sc-field-name="Describe what the proposed Department or Agency resolution is and why it is not a satisfactory resol" data-sc-field-key="7D2B3C15E7AD4242A78414FFA68B557A" data-val-required="Describe what the proposed Department or Agency resolution is and why it is not a satisfactory resolution to the discriminatory incident. is required." data-val="true"></textarea> <span class="field-validation-valid" data-valmsg-for="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[735de852-359c-42c7-a47d-87ba84fc5887].Value" data-valmsg-replace="true"></span><input id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_Index_2e0886c8-f13d-480f-8869-5a0457e199f1" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields.Index" type="hidden" value="2e0886c8-f13d-480f-8869-5a0457e199f1" /><input id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_2e0886c8-f13d-480f-8869-5a0457e199f1__ItemId" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[2e0886c8-f13d-480f-8869-5a0457e199f1].ItemId" type="hidden" value="2e0886c8-f13d-480f-8869-5a0457e199f1" /><label for="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_2e0886c8-f13d-480f-8869-5a0457e199f1__Value" class="">Date of discriminatory incident</label> <input type="date" id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_2e0886c8-f13d-480f-8869-5a0457e199f1__Value" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[2e0886c8-f13d-480f-8869-5a0457e199f1].Value" class="" data-sc-tracking="True" data-sc-field-name="Date" data-sc-field-key="F8EF00158F594587B29192DCF9A2B80B" data-val-required="Date of discriminatory incident is required." data-val-date="The field Value must be a date." data-val="true"/> <span class="field-validation-valid" data-valmsg-for="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[2e0886c8-f13d-480f-8869-5a0457e199f1].Value" data-valmsg-replace="true"></span><input id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_Index_658ff507-77a5-4aaf-b89c-85f9c387f5bd" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields.Index" type="hidden" value="658ff507-77a5-4aaf-b89c-85f9c387f5bd" /><input id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_658ff507-77a5-4aaf-b89c-85f9c387f5bd__ItemId" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[658ff507-77a5-4aaf-b89c-85f9c387f5bd].ItemId" type="hidden" value="658ff507-77a5-4aaf-b89c-85f9c387f5bd" /><label for="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_658ff507-77a5-4aaf-b89c-85f9c387f5bd__Value" class="">Which State of Michigan Department or Agency was involved</label> <select id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_658ff507-77a5-4aaf-b89c-85f9c387f5bd__Value" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[658ff507-77a5-4aaf-b89c-85f9c387f5bd].Value" class="" data-sc-tracking="True" data-sc-field-name="Dropdown List" data-sc-field-key="BE47C7DA39044B588DD6024D3605FF7C" > <option label=" "></option> <option value="Aging and Adult Services Agency">Aging and Adult Services Agency</option> <option value="Agriculture and Rural Development">Agriculture and Rural Development</option> <option value="Attorney General">Attorney General</option> <option value="Auditor General">Auditor General</option> <option value="Civil Rights">Civil Rights</option> <option value="Civil Service">Civil Service</option> <option value="Corrections">Corrections</option> <option value="Court of Appeals">Court of Appeals</option> <option value="Education">Education</option> <option value="Environmental Quality">Environmental Quality</option> <option value="Health and Human Services (CH)">Health and Human Services (CH)</option> <option value="Health and Human Services (HS)">Health and Human Services (HS)</option> <option value="House of Representatives">House of Representatives</option> <option value="Insurance and Financial Services">Insurance and Financial Services</option> <option value="Legislative Service Bureau">Legislative Service Bureau</option> <option value="Licensing and Regulatory Affairs">Licensing and Regulatory Affairs</option> <option value="Lottery">Lottery</option> <option value="Michigan Economic Development Corp">Michigan Economic Development Corp</option> <option value="Michigan Gaming Control Board">Michigan Gaming Control Board</option> <option value="Michigan State Housing Development Authority">Michigan State Housing Development Authority</option> <option value="Michigan Strategic Fund">Michigan Strategic Fund</option> <option value="Military and Veteran Affairs">Military and Veteran Affairs</option> <option value="Natural Resources">Natural Resources</option> <option value="Office of the State Employer">Office of the State Employer</option> <option value="Secretary of State">Secretary of State</option> <option value="Senate">Senate</option> <option value="State Police">State Police</option> <option value="Supreme Court & State Court Administrator">Supreme Court & State Court Administrator</option> <option value="Technology, Management and Budget">Technology, Management and Budget</option> <option value="Transportation">Transportation</option> <option value="Treasury">Treasury</option> <option value="Trial Courts">Trial Courts</option> <option value="Workforce Development Agency">Workforce Development Agency</option> </select> <span class="field-validation-valid" data-valmsg-for="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[658ff507-77a5-4aaf-b89c-85f9c387f5bd].Value" data-valmsg-replace="true"></span><input id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_Index_7da1f547-c212-4202-a1a4-5bdef626abc8" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields.Index" type="hidden" value="7da1f547-c212-4202-a1a4-5bdef626abc8" /><input id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_7da1f547-c212-4202-a1a4-5bdef626abc8__ItemId" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[7da1f547-c212-4202-a1a4-5bdef626abc8].ItemId" type="hidden" value="7da1f547-c212-4202-a1a4-5bdef626abc8" /><label for="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_7da1f547-c212-4202-a1a4-5bdef626abc8__Value" class="">Complaint Issue</label> <select id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_7da1f547-c212-4202-a1a4-5bdef626abc8__Value" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[7da1f547-c212-4202-a1a4-5bdef626abc8].Value" class="" data-sc-tracking="True" data-sc-field-name="Complaint Issue" data-sc-field-key="AF2EA7BC53534623B1CF19B6CBF4E4A4" data-val-required="Complaint Issue is required." data-val="true"> <option label=" "></option> <option value="Denial of Services/Refusal to Admit">Denial of Services/Refusal to Admit</option> <option value="Employment">Employment</option> <option value="Housing">Housing</option> <option value="Interpreter/Assistive Listening">Interpreter/Assistive Listening</option> <option value="Physical Access">Physical Access</option> <option value="Reasonable Accommodation">Reasonable Accommodation</option> <option value="Retaliation">Retaliation</option> <option value="Service Animal">Service Animal</option> <option value="Other">Other</option> </select> <span class="field-validation-valid" data-valmsg-for="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[7da1f547-c212-4202-a1a4-5bdef626abc8].Value" data-valmsg-replace="true"></span><input id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_Index_88bfb6b4-755b-4a4e-a1b4-89bf45f99849" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields.Index" type="hidden" value="88bfb6b4-755b-4a4e-a1b4-89bf45f99849" /><input id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_88bfb6b4-755b-4a4e-a1b4-89bf45f99849__ItemId" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[88bfb6b4-755b-4a4e-a1b4-89bf45f99849].ItemId" type="hidden" value="88bfb6b4-755b-4a4e-a1b4-89bf45f99849" /><label for="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_88bfb6b4-755b-4a4e-a1b4-89bf45f99849__Value" class="">If Other is selected please describe what the type of complaint is</label> <textarea id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_88bfb6b4-755b-4a4e-a1b4-89bf45f99849__Value" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[88bfb6b4-755b-4a4e-a1b4-89bf45f99849].Value" class="" rows="4" maxlength="512" placeholder="" data-sc-tracking="True" data-sc-field-name="If Other is selected please describe what the type of complaint is" data-sc-field-key="626B9E9AD08249509D1A494D4B457913" data-val-required="If Other is selected please describe what the type of complaint is is required." data-val="true"></textarea> <span class="field-validation-valid" data-valmsg-for="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[88bfb6b4-755b-4a4e-a1b4-89bf45f99849].Value" data-valmsg-replace="true"></span><input id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_Index_c5caa730-2a7a-42ac-a7f1-b41822496c94" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields.Index" type="hidden" value="c5caa730-2a7a-42ac-a7f1-b41822496c94" /><input id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_c5caa730-2a7a-42ac-a7f1-b41822496c94__ItemId" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[c5caa730-2a7a-42ac-a7f1-b41822496c94].ItemId" type="hidden" value="c5caa730-2a7a-42ac-a7f1-b41822496c94" /><label for="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_c5caa730-2a7a-42ac-a7f1-b41822496c94__Value" class="">List your primary ADA qualified disability</label> <textarea id="fxb_2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f_Fields_c5caa730-2a7a-42ac-a7f1-b41822496c94__Value" name="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[c5caa730-2a7a-42ac-a7f1-b41822496c94].Value" class="" rows="4" maxlength="512" placeholder="" data-sc-tracking="True" data-sc-field-name="List your primary ADA qualified disability" data-sc-field-key="C7A83543B9604731B509ECCFDBDE63C1" data-val-required="List your primary ADA qualified disability is required." data-val="true"></textarea> <span class="field-validation-valid" data-valmsg-for="fxb.2396fc0a-c8b1-41f0-b389-c3dcb0e41e5f.Fields[c5caa730-2a7a-42ac-a7f1-b41822496c94].Value" 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State of Michigan ADA Appeal Form