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ADA Grievance Form

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* Denotes a required field

Complainant Information

First Name*

Last Name*

Address*

City*

State*

ZIP*

Zip-Zip +4
Second portion of ZIP Code is optional.

Phone*

Phone Area Code-Phone 3-Phone 4 ext Extension

Preferred Methods of Communications (check all that apply, hold ctrl down to select multiple)*

Situation

Describe your complaint of discrimination based upon disability*

! Be specific and give dates(s), time(s) and location(s)

Persons named in your complaint*

! List the names of (or describe) all persons involved in your complaint. Indicate the job title and County Department if possible.

Additional Information

Witnesses to your complaint*

! List the names of (or describe) all persons involved in your complaint. Indicate the job title and County Department, if possible.

Please Do Not Complete The Following Field

Evidence and documentation*

! List and provide any physical evidence, written or recorded documents, or any other information that directly supports your specific claim of discrimination.

Case remedy and/or resolution*

! What remedies or resolutions are you seeking?

Certification

I hereby certify that the information and statements provided are true.

Signature*

As a form of signature, type your full name above.

If Complainant is not the individual completing this form, please provide:

Representative's Name

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Representative's Phone

Phone Area Code-Phone 3-Phone 4 ext Extension

Dialog Title

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