Grambling State University
Division of Student Affairs
 ADA Student Services


Information contained in this appeal form is confidential and should only be reviewed by those who have a need to know. If at any time the complainant feel that he/she is adversely targeted because of filing this appeal, the complainant should consult immediately with the University EEO Officer.

The Complainant should receive a response to the appeal within 20 full working days of submitting the appeal. If the decision is delayed because of a need for a more thorough investigation, the complainant should be notified and a new response date will be identified.

Name of Complainant Social Security Number
On Campus Address Telephone Number
Home Address Home Telephone Number
Basis for the Appeal
Thoroughly explain your reason for the appeal (Use the reverse side of this form and additional paper if needed).

Do you have additional Information that you have not shared previously, explain or list items? (Submit all additional information with this appeal.)


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Name (Please Print)                                                                 Signature                                                                 Date