ADA Complaint Form

Date of Incident

Name

Phone

Home Address

City

State

Zip Code

Location

Location of Incident

Other Locations

Incident Description

What would you like the ADA Coordinator to do to resolve your complaint?

I certify that the information provided is accurate to the best of my knowledge. I understand and consent to the disclosure of information contained in this complaint to the appropriate personnel and witnesses interviewed for the purpose of investigating and resolving this complaint."