ADA Grievance Form

Download a copy of the Grievance Form HERE

Name (Complainant):

Home Address:

City:

State:

Zipcode:

Phone:

Email:

Person discriminated against (if other than complainant)

Name:

Address:

City:

State:

Zipcode:

Phone:

Name of person(s) who allegedly discriminated against you, if known:

Date of alleged incident:

Location of alleged incident:

Type of alleged discrimination:

Explain what happened to you and how you believe you were discriminated against (how you feel other person were treated differently than you). Indicate who was involved and explain their role:

Fully identify any person(s) we may contact for additional information to support or clarify your allegations (name, address, telephone(s)):

Any other information you have which is relevant to an investigation of this complaint:

How can your issues be resolved to your satisfaction?

If you have filed this complaint with ECAT before, please specify when, where, and how:

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