ADA Complaint / Grievance form

2. ADA Grievance Form
   Title II of the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973

   Title II of the Americans with Disabilities Act, Section 504 of the Rehabilitation Act of 1973

4. Complainant Name*

6. Designee Preparing Complaint (if different from Complainant)

7. Designee's Relationship to Complainant

9. Street Address*

11. City*

12. State*

13. Zip*

15. Phone number*

16. Email address

20. Please provide a complete description of the specific complaint or grievance.*

    .

22. Please specify any location(s) related to the complaint or grievance (if applicable).

24. Please state what you think should be done to resolve the complaint or grievance.

26. Do you wish to be contacted regarding this situation?

    1. Please do not contact me personally
    2. Yes

28. If you have any additional pages, those can be uploaded here.

30. E-signature*

31. Today's date*
    Today's date

Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field