ADA Complaint Form

Name (First, Middle Initial, and Last)(Required)

Home Phone(Required)

Business Phone

Address

State Agency Accused of Denying Disability Access

Skip this section if you are filing this complaint for yourself.

Name (First, Middle Initial, and Last)(Required)

Home Phone(Required)

Business Phone

Person Denied Disability Access

Agency(Required)

Department (if applicable)

Agency Address

Phone Number

Incident Details

Date(Required)

Describe the denial of disability access or discrimination providing the name(s) where possible of the individuals who discriminated:(Required)

Have efforts been made to resolve this complaint through the internal grievance procedure of the State Agency:*

Yes

If yes, what is the status of the grievance?:

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

Yes

If yes:

Agency or Court

Contact Person

Address

Phone Number

Date Filed

If applicable.

Name (First, Middle Initial, and Last)

Home Phone

Business Phone

Address

May we contact this witness?

Yes

Complaint Acknowledgement

By clicking submit, you certify the information provided is accurate to the best of your knowledge. You understand and consent to the disclosure of information contained in this complaint.