MDW Americans with Disabilities Act Complaint Form

Complainant Information
Complainant Name:*

First NameLast Name
Email Address:*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Individual (if other than complainant) Alleging an ADA Violation
Complainant Name:

First NameLast Name
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number
Please enter a valid phone number.
MDW Airport Service, Program or Facility Allegedly in Violation
Date of Alleged Violation:*

DayMonthYear
Time of Alleged Violation*

Minutes

AM/PM Option
If traveling, state Airline used:
Location of Alleged Violation: (Describe as clearly as possible the implicated area or location at or within Chicago Midway International Airport where the alleged violation occurred.)*
Description of Service, Program or Facility Involved: (Describe as clearly as possible the nature of the program, service or facility relating to the alleged violation; i.e. – wheelchair assistance, ground transportation, airport concession, etc.)*
Description of Alleged Violation and any Requested Remedy: (Explain as clearly as possible what happened and why you believe the happening is an alleged violation. Include details on any person(s) or company(s) involved, including contact information for said individuals or companies where available. Include details on any witnesses which may have witnessed the incident.)*
Has a complaint regarding the alleged violation been filed with any other federal, state or local agency, or within any Federal or State Court?*

YesNo
If answering “Yes” to the previous question, please provide the following details:
Agency or Court:
Case Name / Docket No.:
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date

DayMonthYear
Date
Phone Number
Additional Comments or Details:
Date

MonthDayYear
Clicking this box serves as a signature and confirmation that all information in this complaint form is accurate.
Please verify that you are human*
Should be Empty:

Complainant Information

Individual (if other than complainant) Alleging an ADA Violation

MDW Airport Service, Program or Facility Allegedly in Violation

If answering “Yes” to the previous question, please provide the following details: