Title II of the Americans With Disabilities Act
Accessibility Complaint Form
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Daytime Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please provide the following information
Date of incident
-
Month
-
Day
Year
Date Picker Icon
Manner in which accessibility to facilities, services, programs or activities was denied or impaired:
Location and Department
Please describe the incident or barrier to County facilities services programs or activities Attach additional pages if necessary
Do you wish to make an informal, confidential presentation of your complaint to the ADA Accessibility Coordinator?
Yes
No
What actions do you request be taken to correct the accessibility problem:
Signature
Signature
Submit
Should be Empty: