City of Edina Form Center

ADA Title II Grievance

2. Complainant's Name
4. First Name*
5. Last Name*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number
14. Email Address
18. Individual Discriminated Against (if other than complainant) Information
20. First Name
21. Last Name
23. Address
25. City
26. State
27. Zip Code
29. Phone Number
30. Email Address
34. Alleged Violation
36. Date of Occurrence*
    Date of Occurrence
38. Describe the Violation and City Department Involved:*
40. What efforts have been made to resolve this complaint using the internal grievance procedures of the City Department?*
44. Documentation
    If you have any documentation (letters, emails, messages, written notes, etc.), please upload them.
46. Supporting Document 1
48. Supporting Document 2
50. Supporting Document 3
54. Other Filing of This Incident
56. Has this complaint been filed with a State or Federal Agency?*

    1. Yes
    2. No
58. If yes, can you provide additional details?
60. Date Filed
    Date Filed
61. Contact Person
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit

* indicates a required field