a) If an individual desires to file a formal written grievance, the individual shall promptly, but no later than 180 days after the alleged discrimination, submit the grievance to the Designated Coordinator in writing on the grievance form prescribed for that purpose. The grievance form shall be completed in full in order to receive proper consideration by the Designated Coordinator, and shall include:

1. 1) the complainant's name, address and telephone number;
2. 2) the best means and time for contacting the complainant;
3. 3) the program, activity, or service which was denied the complainant or in which alleged discrimination occurred;
4. 4) the date and nature of the alleged denial or discrimination; and
5. 5) the signature of the complainant.