Grievance Form
This form is to be used if you have a grievance against DRA for not taking your case or completing your objective.
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I am a...
Please Select
Client or prospective client
Representative of a client or prospective client
Family member of a client or prospective client
Representative of a family member of a client or prospective client
Please explain why you are filing a grievance.
What do you want Disability Rights Arkansas to do differently?
Submit
Should be Empty: