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ADA Title II Grievance

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Complainant's Name
First Name*
Last Name*
Address*
City*
State*
Zip Code*
Phone Number
Email Address
Individual Discriminated Against (if other than complainant) Information
First Name
Last Name
Address
City
State
Zip Code
Phone Number
Email Address
Alleged Violation
Date of Occurrence*
Date of Occurrence
Describe the Violation and City Department Involved:*
What efforts have been made to resolve this complaint using the internal grievance procedures of the City Department?*
Documentation
If you have any documentation (letters, emails, messages, written notes, etc.), please upload them.
Supporting Document 1
Supporting Document 2
Supporting Document 3
Other Filing of This Incident
Has this complaint been filed with a State or Federal Agency?*
1. Yes
2. No
If yes, can you provide additional details?
Date Filed
Date Filed
Contact Person