Title

Reasonable accommodation/grievance form for people with disabilities

Community Outreach and Engagement Links

Sections

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Use this form:

To request a reasonable accommodation accessing the City's services, programs, or activities due to a disability, or
To file a disability-related grievance.

Within 10 business days of receipt of this form, the City's ADA coordinator and appropriate staff will review your submission. During the evaluation process, the City may follow up with you to gather additional information about your reasonable accommodation request and to determine how to provide you with access to City services, programs or activities.

Contact info for person submitting this form

First

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone

Email

Are you making this request on someone"s behalf?

Yes

No

Contact info for whom you're submitting this form

First

Last

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone

Email

Is this a request for accommodation or a complaint?

Request for accommodation

Reasonable accommodation complaint

Description of desired service, program, or activity:

City Department/Division involved (if known)

What action(s) should the City to take to assist you?

Do NOT provide information not related to your request.

Do NOT enter sensitive medical information.

Requested start date

Requested end date

Complaint

Alleged violation

Start date of occurrence

End date of occurrence

Leave blank if ongoing

City Department/Division involved (if known)

Requested City action to correct alleged violation

Have you filed the complaint another federal, state, or local civil rights agency or court?

Yes

No

Other agency

Name of agency

Date filed

Contact Information

Community Outreach and Engagement Division

952-563-8733

Email staff