Contact Information

Contact Information

Community Outreach and Engagement Division

Title

Reasonable accommodation request or grievance form

Sections

Please complete this form ...

  • To request a reasonable accommodation to access the City of Bloomington’s services, programs, or activities, or
  • To file a grievance.

Within 10 business days of the City’s receipt of this form, the ADA Coordinator and appropriate staff will review your submission. During the evaluation process, the City may follow-up with you and engage in an interactive process to gather additional information about your reasonable accommodation request and to determine what will allow you access to the City’s services, programs, or activities.

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Reasonable accommodation form
Contact info for person submitting this form
Name
Address
Are you making this request on someone"s behalf?
Contact info for whom you're submitting this form
Name
Address
Is this a request for accommodation or a complaint?
Request
Do NOT provide information not related to your request. 

Do NOT enter sensitive medical information.
Complaint
Leave blank if ongoing
Have you filed the complaint another federal, state, or local civil rights agency or court?
Other agency

Please take notice that any data received by the City as the result of submitting this form will be classified as government data pursuant to the Minnesota Government Data Practices Act, Minnesota Statutes Chapter 13. Under the Data Practices Act, some or all of this data is classified as public data, including your name, address, email address, phone number, and other personal information provided by you. Public data is available to anyone requesting it and consists of all data furnished via this Web form. Please be advised that the correspondence will be added to the public record. The purpose and intended use of the information collected through this form is to obtain public input and data in support of City activities and services. You have the right to refuse to submit this form. If you choose not to submit this form, you will need to contact the City by another means if you wish to provide the information collected by the form.

The City of Bloomington does not discriminate against or deny the benefits of its services, programs, or activities to a qualified person because of a disability. To make a request for a reasonable accommodation, ask for more information, or to file a complaint, contact the Community Outreach and Engagement Division, City of Bloomington, 1800 West Old Shakopee Road, Bloomington, MN 55431- 3027; 952-563-8733, MN Relay 711.