ADA Title II Grievance Form | Department on Disability

Instructions: Please fill out as much of this form as you can in black ink or type. If you need assistance, tell us and we would be happy to provide assistance with filling out this form. Sign and return (mail, fax or e-mail) to the following information listed below.

Department on Disability
Disability Access and Services ADA Compliance Officer
201 North Figueroa Street, Suite 100
Los Angeles, CA 90012
Phone: (213) 202-2766
Fax: (213) 202-2715
E-mail: DOD-ADA@lacity.org

Name *

Address *

City *

State *

Zip Code *

Telephone (Home)

Telephone (Business)

Telephone (Mobile)

E-Mail

Person (if other than the grievant) alleging Violation of Title II of the Americans with Disabilities Act:

Address

City

State

Zip Code

Telephone (Home)

Telephone (Business)

Telephone (Mobile)

COMPLAINT

Access issues generally fall into one of three categories, please indicate which category best describes your issue.

Physical/Architectural Access – Is the issue related to a physical barrier, for example, a wheelchair ramp is needed, counters are too high for wheelchair users, missing braille signage, etc.

Programmatic Access – Is the issue related to being able to participate in a program, service or activity. For example, is there a City policy, practice, and/or procedure that you allege does not provide an equally effective opportunity for persons with disabilities to participate in or benefit from the City’s programs and services.

Communication Access – Is the issue related to communication, for example do you need auxiliary aids and services, a sign language interpreter, Communication Access Real-Time Translation (CART) materials in alternative formats in order to have equal access to information and communication with a City Department’s programs, services or activities.

City Department, Bureau or Service *

Address *

City *

State *

Zip Code *

Telephone *

When did the alleged violation occur? *

Month

Day

Year

Describe the alleged act(s) of discrimination, providing name(s) where possible of the individuals who allegedly violated Title II. *

Has this complaint been filed with the Department of Justice or any other Federal, State, or local civil rights agency or court? *

Yes.

No

If yes, please complete the following information below.

Agency or Court

Contact Person

Address

City

State

Zip Code

Telephone

Date Filed

Month

Day

Year

Additional space for description of alleged act of violation

Strict confidentiality of all complaint information will be maintained. Sharing of information will be done only as needed to resolve the complaint.

Signature

Date

Month

Day

Year