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4. ADA Formal Written Comlaint Form

   Please use this form to make a formal Americans with Disabilities Act (ADA) Complaint. Your complaint will be reviewed and someone will be in touch with you within 15 days of submittal.

6. Reporting Individual
7. Date of Request
9. Address:
11. City
12. State
13. Zip Code
15. Phone Number
16. Other Contact Information
18. If the person needing the accommodation is not the individual completing this form, please complete below:
20. Name
21. Telephone Number
23. Other Contact Information
27. Program/Facility found to be inaccessible:
29. When did the situation occur (date)?
31. Describe the situation or way in which the program is not accessible, providing the name(s) where possible of the individuals who were involved in the situation, and any documentation or photographs supporting the incident.
33. Upload photos or supporting documents
35. Have efforts been made to resolve this complaint through the Request for Accommodation with the ADA Coordinator?

    1. Yes
    2. No
37. If yes, what were the results?
39. How do you suggest this issue be remedied?
41. Date accommodation is needed:
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field