Grievance Form

This form should only be used when filing a grievance against Disability Rights Pennsylvania (DRP).

If you are looking for assistance with a disability related matter, please do not use this form. Instead, please use our Intake Form.

You can access DRP's Grievance Policy by clicking here.

Puede acceder a la Política de Quejas de DRP haciendo clic aquí

You may file a grievance for any of the following reasons:

1) DRP's denial of assistance to a person with a disability

2) the type and/or quality of assistance provided by DRP

3) the decision to close a case by DRP.

Do you wish to file a grievance against Disability Rights Pennsylvania?*

YesNo

This form should only be used when filing a grievance against Disability Rights Pennsylvania for the above reasons.

If you are looking for assistance with a disability related matter, please use our Intake Form.

Your Name*

First NameLast Name

How would you like us to contact you?*

Relationship to person with a disability*

Name of Person with a Disability*

First NameLast Name

Address of person submitting form on behalf of a person with a disability

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email of person submitting form on behalf of a person with a disability

example@example.com

Phone number of person submitting form on behalf of a person with a disability

Please enter a valid phone number.

Address of person with a disability

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone number of person with a disability

Please enter a valid phone number.

Email of person with a disability

example@example.com

Reason for Grievance*

Please verify that you are human*