ADA Grievance Form

Complainant:

Person Preparing Complaint (if different from Complainant):

Relationship to Complainant (if different from Complainant):

Address

City

State

Zip Code

Phone

Email

Please provide a complete description of the specific complaint or grievance:

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

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

Please attach additional pages as needed.

E-Signature

Date