2. Americans with Disabilities Act Title II Grievance Form
   Form for accessibility concerns.
4. Today's Date:
6. Complainant Name:
8. Street Address:
10. City, State, Zip:
12. Telephone:
13. Email:
15. Individual discriminated against (if other than complainant).
17. Name:
19. Street Address:
21. City, State, Zip:
23. Telephone:
24. Email:
26. Alleged violation: Date(s) of occurrence:
28. Describe violation and City Department involved:
30. What efforts have been made to resolve this complaint using the internal grievance procedures of the City Department:
32. If you have documentation, copies would be helpful. Examples are letters, email messages, written notes, etc.
34. Has a complaint been filed with State or Federal Agency?

    1. Yes

    1. No
36. Name of Agency
37. Date Filed:
39. Contact Person:
41. TENNESSEN WARNING
43. The data you supply on this form will be used to process the ADA grievance you are submitting. You are not legally required to provide this data, but we will not be able to process the ADA grievance without it. The data will constitute a public record if and when the ADA grievance is submitted.
45. Electronic Signature
    By typing your name, this serves as electronic signature to the information stated above.
Leave This Blank:


47. 1. Receive an email copy of this form.
48. Email address

    This field is not part of the form submission.

49. Submit

* indicates a required field