Americans with Disabilities Act Grievance Form

Please provide the following information.

* Denotes required field

Name *

Address *

City *

State *

Zip *

Home Phone *

Cell Phone

Email *

Date the aggrieved action occurred or was observed

Name of program or service

Address

City

State

Zip

Name(s) of the County employee representative with whom you made contact regarding the subject of this grievance

Describe why you believe you are the victim of discrimination on the basis of disability in the delivery of County programs and services