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ADA Grievance Form

  1. Section 1. Contact Information
  2. Section 2. Complainant Information
  3. Are you filing this complaint on your own behalf?
  4. If yes, skip to section 3.
  5. If No, please provide the following contact information for the person discriminated against:
  6. Section 3. Incident Description
  7. Section 4. Incident Information
  8. Have you discussed your complaint with a County employee?
  9. Have you filed your complaint with a federal, state, or local agency; or with a federal or state court?
  10. Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

  11. By inputting my name below, I affirm that the above is true to the best of my knowledge, information, and belief.
  12. Leave This Blank:

  13. This field is not part of the form submission.