Americans With Disabilities Act (ADA) Resident Complaint Form

Americans With Disabilities Act (ADA) Resident Complaint Form

For Reporting ADA Violations or Discrimination in the City of Somerville, MA
Grievance Procedures

The following grievance procedure is established to meet the requirements of the Americans with Disabilities Act (“hereinafter ADA”). It may be used by anyone who wishes to file a complaint alleging discrimination on the basis of disability in employment practices and policies, and/or the provision of services, activities, programs, and benefits by the City of Somerville.

The complaint should be in writing and contain information about the alleged discrimination such as name, address, phone number of complainant and location, date, and description of the problem. Alternative means of filing complaints, such as personal interviews or a tape recording of the complaint will be made available upon request to persons with disabilities who are unable to submit a written complaint.

The complaint should be submitted by the grievant and/or their designee as soon as possible but no later than 60 calendar days after the alleged violation to the following address, OR by submitting this electronic form.

ADA COORDINATOR
City of Somerville
93 Highland Avenue
Somerville, MA 02143
617-625-6600 x2059

Within 15 calendar days after receipt of the complaint, the ADA Coordinator will meet with the complainant to discuss the complaint and possible resolutions. Within 15 calendar days after the meeting, the ADA Coordinator will respond in writing and, where appropriate, in a format accessible to the complainant, such as audiotape. The response will explain the position of the City of Somerville and offer options for substantive resolution of the complaint.

If the complainant believes that the response by the ADA Coordinator does not satisfactorily resolve the issue, the complainant and/or their designee may appeal the decision of the ADA Coordinator within 15 calendar days after receipt of the response to the City Council or their designee.

Within 15 calendar days after receipt of the appeal, the City Council or their designee will meet with the complainant to discuss the complaint and possible resolutions. Within 15 calendar days after the meeting, the Board of Alderman or their designee will provide in writing and, where appropriate, in a format accessible to the complainant such as audiotape, a final resolution of the complaint.

All complaints received by the ADA Coordinator appeals to the City Council or their designee, and responses from the ADA coordinator and the City Council or their designee will be kept by the City of Somerville for at least three years.

Be further advised that any individual who feels aggrieved need not exhaust their administrative remedies at the local level before filing a complaint with a state or federal agency.

What is the nature of your complaint?

I want to report an area I believe to be in violation of the Americans with Disabilities Act, Massachusetts Architectural Access Board regulations, or any other law or regulation.I want to report an act of discrimination against myself or another person with a disability.

Complainant
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.
Alternate Phone Number 1
Please enter a valid phone number.
Alternate Phone Number 2
Please enter a valid phone number.
Email*
example@example.com
Person Alleged To Be Discriminated Against (if Other Than the Complainant)

First NameLast Name

Complaint
Discriminatory Incident
Government, Organization, Institution or Business Which You Believe Has Discriminated*
Address Where Incident Occurred

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (of the Government, Organization, Institution or Business)
Please enter a valid phone number.
Date Discrimination Occurred*

MonthDayYear
Date
Primary Type of Disability
What happened? Please describe the alleged acts of discrimination in the fields below.
Describe the issue in detail and upload any additional information that might be helpful (i.e. photographs). PLEASE NOTE: The combined size of your file uploads cannot exceed 10.5 MB. If you need to share larger files, please share your files using Dropbox/Google Drive/iCloud/One Drive etc. and paste the link below.*
Upload files

Cancelof
Have efforts been made to resolve this complaint through the internal grievance procedure of the government, organization, institution or business? Please describe those efforts.*
Has the complaint been filed with any other Federal, State, or local civil rights agency or court? If yes, please indicate time and place of filing.*
List the location of the area believed to be in violation of the Americans with Disabilities Act, Massachusetts Architectural Access Board regulations, or any other law or regulation. Please give the complete street address and/or street intersection.*
List any individuals and/or agencies with whom you discussed this issue.
Date*

MonthDayYear
Date
Should be Empty:

Americans With Disabilities Act (ADA) Resident Complaint Form

Grievance Procedures

Complainant

Complaint

Discriminatory Incident

What happened? Please describe the alleged acts of discrimination in the fields below.