Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities
REASONABLE ACCOMMODATIONS
POLICY STATEMENT
Pursuant to 29 CFR § 32,29 CFR § 37 AND section 504 of the Rehabilitation Act; Chautauqua Works
and any recipients of Title I WIA funding, have a commitment to ensuring that qualified individuals
with disabilities, who make requests for reasonable accommodations enjoy: services, employment, aid,
benefits, or training programs1, that are equally effective2 and in the most integrated setting3.
•
Who is considered to be a qualified individual with a disability?
A qualified individual with a disability is either:
a. a person who can perform the essential functions of the job with or without a reasonable
accommodation; or
b. a person who meets the eligibility criteria for the receipt of or participation in: the
program, services, or employment sought.4
• What is a reasonable accommodation?
A reasonable accommodation may consist of either adjustments or modifications to:
a. the application/registration process;
b. work environment;
c. employment practices;
d. equipment;
e. structure/facility; or
f. the manner in which programs/services are conducted.5
Qualified customers, employees, and applicants/registrants with disabilities, who seek an
accommodation, are thereby encouraged to make their requests where applicable, to either the
designated on-site staff person or the Disability Program Navigator.
1
29 CFR § 32.3(5)(III) AND united States Department of Labor, “Methods of Administration Under the Workforce
Investment Act: Training for EO Officers and Implementation Staff Participant Guide”, p.5-3, November 2002.
2
29 CFR § 32.4(b)(vii)(2)
3
29CFR § 32.4((7)((II)(d)
4
29 CFR § 32.3(III)(a), (b) and (c)
5
29 CFR § 32.3
Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities
REQUEST FOR REASONABLE ACCOMMODATIONS
INSTRUCTIONS: Complete Section A and sign. (1) Please attach a physician’s statement describing the limitations
placed on your life functions and activities, and (2) how a reasonable accommodation will enable the applicant to execute
the duties described. If necessary, where applicable, please contact the on-site Disability Program Navigator or designated
staff person for assistance. Once completed provide the form and completed physician’s statement to either the on-site
Disability Program Navigator or designated staff person. All information received pertaining to your request will be kept
confidential, maintained separately from personnel records, and used only for record keeping and affirmative action efforts.
Section A: Description
1. Last Name
2. First Name
3. Title
4. Div/Bur
5. Location
6. Work Telephone
7. Describe your request.
8. Describe how this request will allow you to perform your job.
Applicant’s Signature:
Date:
Section B - Disposition of Request (To be completed by ADA Coordinator)
APPROVAL:
Your request for a reasonable accommodation has been approved. The condition(s) of this accommodation is (are):
DISAPPROVAL:
This request is denied for the following reason(s):
Date: ________________________
DPN/504 Monitor: _________________________________________
Section C: Review by Equal Opportunity Officer
I have reviewed this Request for a Reasonable Accommodation and agree with the findings of the ADA Coordinator.
Date: ________________________
Equal Opportunity Officer: __________________________________
In the case of a denial there are several options which may be pursued. Please see the reverse side of this form for a
description of these options.
Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities
Options
Appeal the denial
Internal
Discrimination
Complaint
Process
External
Discrimination
Procedures
Compliance Review Board: The External Review Process involves the review of a request by a panel
of employees from Chautauqua Works. The panel is an advisory body and the Equal Opportunity
Officer is the Chairperson of the Committee. After reviewing your request, the panel will notify the
Agency. The Equal Opportunity Officer will either concur with the panel’s decision or ask the panel
to reconsider.
If you choose to use this process, sign the authorization below in Section D and return this form to the
ADA Coordinator within ten business days after receipt of the denial of the request. The ADA
Coordinator will forward the form within five business days to the Equal Opportunity Officer. The
process takes approximately 15 business days and starts once the request is sent from the
Department. Within ten business days the Board will render its opinion. The ADA coordinator will
then inform you in writing of the final determination and send you a copy of the Board’s
recommendation.
A complainant has the right to file an internal discrimination complaint if he/she feels that denial of
the request was an act of discrimination. The procedure for filing an internal discrimination
complaint with Chautauqua Works is explained in the Notice of Rights. Such complaints must be
filed within 180 days from when the denial of the request was received.
CRC - A complainant may file a complaint directly with the Civil Rights Center (CRC), and has 180
days from when the denial of the request for an accommodation was received. A complainant may
also decide to file with CRC after their complaint has been reviewed by Chautauqua Works; in this
instance they have 30 days from when they received their determination to appeal to CRC.
EEOC - An individual may file a charge of discrimination under the Americans with Disabilities Act
(ADA) with the Equal Employment Opportunity Commission (EEOC), as long as it is within300 days
from the denial of the request by Chautauqua Works.
New York State Human Rights Law - Under the disability discrimination provisions of the New
York State Human Rights Law, an individual may file a charge of discrimination at the NYS Division
of Human Rights within one year of the denial, or file a lawsuit in the New York State Supreme
Court within three years of the denial.
Section D - Authorization for External Review
I authorize Chautauqua Works to release all information pertaining to my request for a reasonable accommodation
to the New York State Department of Labor. This information will be used by the panel to evaluate my request for
an accommodation.
Signature: _______________________________________________ Date: ___________________
Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities
Before you File a Grievance
Workforce Investment Act (WIA) funded programs are free services designed to assist you in your search and preparation
for employment.
There may be a time however, that as a participant, you may become dissatisfied with the program or the way you have
been treated. If this is the case you should try to address the issue internally: by first having a discussion with the
responsible individual(s); and if this is not possible, by then seeking a discussion with their supervisor. Addressing the
problem at this level is oftentimes very helpful and typically results in a quick resolution of the matter. If this approach
proves to be unsuccessful and the problem remains unresolved, you should then start the formal grievance process.
How to File a Formal Grievance
Your grievance must be in writing using the attached Local Workforce Investment Act (LWIA) Grievance Form, and
should include the following information:
1.
2.
3.
4.
5.
Your full name, address, and a phone number where you can be reached;
The name and address of the person(s) or organization that the grievance is against;
A Statement of how you would like the matter to be resolved (e.g., if the agency finds in your favor what you
would like to see happen or to receive); and
A clear statement of the facts (e.g., what happened and the dates) the problem occurred); and
Your grievance must be signed and dated.
Grievance Timeline
Step 1 You shall submit a written explanation of the grievance to the Chautauqua Works Coordinator requesting a review
and determination. Day of receipt of the written grievance shall be Day #1. The Coordinator or his/her designee shall
investigate and make a decision. That decision will be issued in writing on or before Day #5. If the matter is not resolved
to your satisfaction you shall have the right to proceed to the second step.
Step 2 On or before Day #10, a complaint shall be submitted to the Executive Director of Chautauqua Works setting forth
the specific nature of the complaint and all facts pertaining to it. The Executive Director shall then have until Day #15 to
resolve the complaint. If it is not resolved to your satisfaction you shall be entitled to a hearing as described in Step 3.
Step 3 You must make a request for a hearing to the Chautauqua County Executive on or before Day #20. You will
receive written notice of the date, time and place of the hearing. You shall have the opportunity to withdraw your request
for the hearing, request rescheduling for good cause, present oral or written evidence, be represented by an attorney or
other person of your choice, and question witnesses or other parties. On or before the 60th Day, a decision shall be made
and communicated to you in writing. If the matter is still not resolved to your satisfaction at this point, you have the right
to proceed to the fourth step.
Step 4 If there is no decision by the 60th Day, or if all the preceding steps have been exhausted without satisfaction, you
shall have the right to request a review of the complaint by the State Hearing Officer. This request must be filed within 10
days of the decision from Step 3 or by the 75th Day if there is no decision. The State Hearing Officer’s decision is final.
Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities
IMPORTANT INFORMATION
STEP 1
Katie Geise
Project Director
Chautauqua Works
23 E. 3rd Street
Jamestown, NY 14701
STEP 2
Dr. Susan McNamara
Executive Director
Chautauqua Works
23 E. 3rd Street
Jamestown, NY 14701
STEP 4
NYS Workforce Investment Act
Hearing Officer
New York State Dept. of Labor
State Office Building Campus
Building 12, Room 440
Albany, NY 12240
Special Note: Any person who has knowledge of a criminal complaint (fraudulent, abusive or criminal activity) relating to
the Workforce Investment Act should report all information directly to:
Elaine L. Chao, Secretary of Labor
Frances Perkins Bldg.
200 Constitution Ave. NW
Washington, DC 20210
and
Office of Inspector General
US Department of Labor
Office of Investigations, Room 55514
200 Constitution Avenue, NW
Washington, DC 20210
STEP 3
Greg Edwards
Executive
Chautauqua County
Gerace Office Building
Mayville, NY 14757
Cynthia Koczaja
New York State Department of Labor
290 Main Street
Buffalo, NY 14202
Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities
Grievance Information Form
Grievant’s Information
1) Name:
2) Home
Phone __________________________________
Address:
Area Code
Number
3) Work
Phone __________________________________
Area Code
Social Security Number:
(disclosure of SS# is voluntary)
Number
4) Cell
Phone __________________________________
Area Code
Number
Respondent’s Information
5) In the space provided, list the name of the
individual(s) and the location of the alleged incident.
(if more space is needed attach additional sheet(s))
6) Provide the date of occurrence
___________________________________________
Provide the date of the most recent incident (if there was
more than one instance) _____________________
7) To the best of your knowledge, which of the
following Department of Labor programs were
involved (Check one)
_____ Chautauqua Works
_____ Unemployment Insurance
_____ Employment Service
_____ Trade Adjustments Assistance
_____ Older Americans
_____ Individual Training Accounts
a) Chautauqua Works
b) Training Provider
_____ Other _____________________________
8) Basis of Grievance: Do you think the discrimination
against you effected: (Check One)
_____ Your job or job search? or
_____ Your use of facilities or someone providing/not
providing you with services or benefits?
If so, which of the following were involved?
____Training
____ Union activity
____ Intimidation/reprisal ____ Union representation
____ Harassment
____ Placement
____ Other
9) Explain as briefly and as clearly as possible what happened. Be sure to indicate who was involved and how other
persons were treated differently from you. If necessary, you may also attach additional written material pertaining
to your case.
10) What other information do you think is relevant to our investigation?
Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities
11) If this grievance is resolved to your satisfaction, what remedies do you seek?
12) Please list below any persons (witnesses, fellow employees, supervisors, or others) that we may contact for
additional information to further support your response. (if necessary feel free to attach additional written material)
13) Have you filed a case or complaint with any of the following?
_____
New York State Department of Labor (NYSDOL)
_____
Federal or State Court
_____
Your State or local human relations/rights commission.
14) For each item checked above, please provide the following information (if you have checked more than one,
attach additional pages)
Agency:
Location of agency or Court:
Date Filed:
Name of Investigator:
Case or Docket Number:
Status of Case:
15)
______________________________________________________
Signature
(the grievance is not valid unless it is signed)
____________________________
Date
Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities
COMPLAINT AND
MEDIATION PROCEDURES
I) The Complaint Procedure
a) Who may file a complaint?
Any person who is a participant in a WIA Title I financially assisted program or activity, and is lawfully authorized to
work in the United States.
A person may file:
1) on their own behalf;
2) on behalf of an individual (as an authorized representative): or
3) on behalf of any specific class of individuals.
b) What are the bases of a discrimination complaint?
A complaint of discrimination must be based on one or more of the following classifications:
•
•
•
•
•
Race
Color
Religion
Sex
National Origin
•
•
•
•
•
Age
Disability
Political Affiliation
Belief or
Citizenship status
c) What are the requirements for filing a complaint?
⇒ Complaints must be filed within 180 days of the alleged incident.
⇒ Complaints must also be in WRITING and must contain the following information:
•
•
•
The complainant’s name and address or other means of contact.
Respondent’s identity or the entity responsible for the alleged discrimination.
A description of the allegations with enough detail to establish:
1) WIA Title I jurisdiction over the complaint;
2) Whether the complaint was filed within the required 180 day time period;
3) Whether the complaint has apparent merit; and
4) Whether the allegations would violate any of the nondiscrimination and equal opportunity
provisions of WIA.
•
The complainant’s or their authorized representative’s signature.
d) When to File?
Complaints must be filed within 180 days from the initial date of occurrence. Complainants who file with an EO
Officer must wait until a written Notice of Final Action is received or until 90 days have passed (whichever is
sooner) before filing with the Civil Rights Center (CRC). The Director of CRC for good cause shown may extend
the filing period beyond 180 days.
Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities
e) Where to File?
Complaints may be filed with the LWIA (Local Workforce Investment Act) EO Officer:
23 E. 3rd Street
Jamestown, NY 14701
Attn: LWIA Equal Opportunity Officer, Jody Cheney
Or
Complainants may also seek to file directly with the:
United States Department of Labor
Civil Rights Center
200 Constitution Avenue, N.W. Room N-4123
Washington, D.C. 20210
Attn: Director
f) When a complaint involves two or more programs?
Questions of Jurisdiction
A complaint will face questions of jurisdiction either when:
1) the complaint stems from an incident that has no connection to a WIA funded program or activity;
or
2) two or more entities are involved.
1) The Complaint has no connection to a WIA funded program or activity
If it is determined that the LWIA EO Officer does not have jurisdiction or authority to process the
complaint, the complainant will be notified accordingly. Notification of a lack of jurisdiction will include
an explanation for the determination, and filing information. If it is found that there is a lack of
jurisdiction, the complainant has a right to file their complaint with the Civil Rights Center (CRC) within
30 days from when they received the lack of jurisdiction notice.
2) Two or more entities are involved
If it is determined that the EO Officer has joint jurisdiction over the complaint (e.g. meaning that the
complaint involves allegations against a WIA funded program and another entity), the complaint will be
forwarded to the appropriate Equal Opportunity Officer and the complainant will be notified accordingly.
However, if a complain is related to programs administered by the New York State Department of Labor
(NYSDOL), complainants should address their complaints to the:
New York State Department of Labor,
Division of Equal Opportunity Development
State Campus Building 12, Room 540
Albany, New York 12240
Attn: Andrew Adams, WIA EO Officer
g) Additionally
Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities
⇒ All parties to the complaint are entitled to representation of their own choosing and at their own expense.
⇒ Upon receipt by the EO Officer, Complaints are assigned a case number, recorded on the complaint log
and forwarded to the appropriate Equal Opportunity Officer. All complaints are handled and maintained
confidentially.
II) MEDIATION AS AN ALTERNATIVE TO THE FORMAL COMPLAINT PROCESS
a) What is Mediation?
Mediation is an efficient, informal, and confidential alternative to the discrimination complaint process. It
involves a good faith agreement by the complainant and the respondent to meet with a neutral mediator to
reach a mutually acceptable resolution of their issue(s).
Complainants will not be offered mediation as an option in instances where there are threats of or the actual
occurrence of violence.
b) An Overview of the Mediation Process
⇒ When a discrimination complaint is received, the EO Officer sends a Statement of the Issues. The
Complainant has 10 days from receipt of the Statement of the Issues to choose mediation in lieu of the
formal discrimination complaint process.
⇒ In order to formally initiate the mediation process, the complainant and respondent must sign a “Consent
to Mediate” form.
⇒ Once the “Consent to Mediate” form has been completed, the EO Officer will contact one of New York
State’s thirty-three (33) regional Community Dispute Resolution Centers (CDRC).
⇒ The mediator will then assume jurisdiction of the complaint for sixty (60) days. Note: this sixty day
period starts upon the CDRC’s receipt of the initial written referral from the EO Officer.
⇒ Within the 60 day period the mediator will conduct a mediation session(s). If the parties reach an
agreement the mediator will assist them in memorializing their understanding in writing.
⇒ Upon completion of the mediation process or within ninety (90) days of the EO Officer’s receipt of the
original complaint of discrimination, the complainant and respondent will receive a Notice of Final
Action indicating the outcome of the proceedings.
⇒ The Notice of Final Action will also provide instructions that the complainant has thirty (30) days from
their receipt of the notice, to file an appeal with the U.S. Department of Labor’s Civil Rights Center.
c) Protection from Intimidation, Reprisal, and Retaliation
⇒ All parties to a discrimination complaint mediation are protected from intimidation, reprisal, and
retaliation.
d) Confidentiality
Unless the parties agree otherwise, mediation sessions will be closed to anyone other than the individual
parties and their representatives. Outside of what is necessary to effectuate the terms of the agreement, any
communications and information disclosed during the course of the mediation process is privileged and
confidential. Copies of the mediation agreement will be filed with the Equal Opportunity Officer, where they
will be stored for three (3) years and subject to review by the U.S. Department of Labor’s Civil Rights
Center.
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e) Breach of the Mediation Agreement
⇒ Written mediation agreements are binding on all parties. If a non-breaching party determines that the
agreement has been breached, they will have 30 days from when the breach was discovered to file a
complaint with the Director of the U.S. Department of Labor’s Civil Rights Center (CRC). If the
Director of the Civil Rights Center determines that a breach occurred, then the complainant will be
permitted to file a new complaint of discrimination.
Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities
Discrimimation Complaint Information Form
Complainant’s Information
1) Name:
2) Home
Phone __________________________________
Area Code
Address:
Number
3) Work
Phone __________________________________
Area Code
Number
4) Cell
Phone __________________________________
Social Security Number:
(disclosure of SS# is voluntary)
Area Code
Number
Respondent’s Information
5) To the best of your knowledge, which of the following Department of Labor programs were involved (Check one)
_____ Chautauqua Works
_____ Individual Training Accounts
_____ Unemployment Insurance
a) Chautauqua Works
_____ Employment Service
b) Training Provider
_____ Trade Adjustments Assistance
_____ Other _____________________
_____ Older Americans
6) Explain as briefly and as clearly as possible what happened and how you were discriminated against. Be sure to
indicate who was involved and how other persons were treated differently from you. If necessary, you may also
attach additional written material pertaining to your case.
7) Provide the date the first incident took place: ___________ Date of Most Recent Occurrence: ___________
8) Which of the following best describes why you believe you were discriminated against? (Please specify)
Basis for
Discrimination
Please Specify
Race
______________________________
Color
______________________________
Religion
______________________________
National Origin ______________________________
Sex
______________________________
Age
______________________________
Disability
______________________________
Political Affiliation ____________________________
Citizenship
______________________________
Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities
9) Do you think the discrimination against you effected: (check one)
Your job or job search
Your use of the facilities or someone providing/not providing you with service or benefits.
Explain as briefly and as clearly as possible what happened and how you were discriminated against. Be sure to indicate
who was involved and how other persons were treated differently from you. If necessary, you may also attach additional
written material pertaining to your case.
10) If this complaint is resolved to your satisfaction, what remedies do you seek?
11) Please list below any persons (witnesses, fellow employees, supervisors, or others) that we may contact for
additional information to further support your response. (if necessary feel free to attach additional written material)
12) Have you filed a case or complaint with any of the following?
_____
New York State Department of Labor4 (NYSDOL)
_____
Federal or State Court
_____
Your State or local human relations/rights commission.
131) For each item checked above, please provide the following information (if you have checked more than one,
attach additional pages)
Agency:
Location of agency or Court:
Date Filed:
Name of Investigator:
Case or Docket Number:
Status of Case:
14)
______________________________________________________
Signature
(the grievance is not valid unless it is signed)
____________________________
Date
Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities
Consent Form
I understand that the following provisions from the Privacy and Freedom of Information Acts apply to the
personal information I reveal to the Department of Small Business Services (SBS) in connection with my
complaint;
In order to obtain the information needed to investigate my complaint, I understand that SBS may have to
reveal my identity to involved parties and staff members.
However, I do not have to reveal any personal information to SBS, but SBS may close my complaint if I
refuse to reveal the information necessary to complete its investigation;
I may request and receive a copy of any personal information SBS keeps in my complaint file for
investigatory purposes; and
Under certain conditions, SBS may be required by the Freedom of Information Act to reveal to others the
personal information I have provided in connection to my complaint.
______________________________________________________________________________________
YES, SBS MAY DISCLOSE MY IDENTITY IF IT IS FOUND TO BE NECESSARY TO
INVESTIGATE MY COMPLAINT. I have read and understand the notice, and I give SBS consent
to process my complaint.
_____________________________________________
(Signature)
_______________________________
(Date)
NO, SBS MAY NOT DISCLOSE MY IDENTITY, EVEN IF IT IS FOUND TO BE NECESSARY
TO PROCESS MY COMPLAINT. I have read and understand the notice, and I do not give SBS
permission (consent) to disclose my identity during the course of its investigation. I request that
SBS process my complaint, however, I understand that SBS may terminate the investigatory
process if they are unable to proceed without disclosing my identity.
Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities
NOTICE OF RIGHTS
WIA GRIEVANCE AND DISCRIMINATION COMPLAINT PROCEDURES
If you feel that your rights have been violated by any persons or entities operating within
the Workforce Investment Act (WIA) (including employees, vendors, or other actors
located within Chautauqua Works), or in connection with a WIA Title I financially assisted
program or activity, you may file a written grievance or discrimination complaint.
The two procedures are distinct and address different issues. A grievance is typically
programmatic in nature. Examples of grievances include but are not limited to: complaints
about the program; the provision of services; and a disagreement with a staff member or an
employee(s). In comparison, a complaint involves discrimination against someone based
on one of the federally protected classifications (e.g. race, color, sex, age, and national
origin).
In both instances, you must file in a timely manner. You have one year to file a grievance
and 180 days to file a complaint.
If you have any questions on how to file a grievance or discrimination complaint, you may
contact the WIA Equal Opportunity Officer or the WIA Grievance Officer for further
assistance.
Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities
WIA Equal Opportunity Officer
Name:
JODY CHENEY
Location:
23 E. 3rd Street
Jamestown, NY 14701
Telephone:
TTY/TDD
716-661-9324
716-487-5117
WIA Grievance Officer
Name:
SUSAN MCNAMARA
Location:
23 E. 3rd Street
Jamestown, NY 14701
Telephone:
TTY/TDD
716-661-9324
716-487-5117
WIA SEC. 504/ADA Officer
Name:
GAIL DONUS
Location:
23 E. 3rd Street
Jamestown, NY 14701
Telephone:
TTY/TDD
716-487-5124
716-487-5117
Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities
Acknowledgement of Receipt of Notice of Rights
I have read this form and understand that I have a right to file a grievance or discrimination
complaint if I feel that my rights were violated by Chautauqua Works or in connection with
a WIA Title I financially assisted program or activity.
I acknowledge receipt of the formal Grievance/Discrimination Complaint/Reasonable
Accommodations policies in addition to this Notice of Rights.
Name (Print):
______________________________________________________
Signature:
______________________________________________________
Date:
______________________________________________________
Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to individuals with disabilities