Title II of the Americans with Disabilities Act Complaint/Grievance Form Larimer County, Colorado

Title II of the Americans with Disabilities Act Complaint/Grievance Form Larimer County, Colorado
Section 1: Name and Contact Info
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Check preferred methods of communication:*

EmailVoice TelephoneUS MailTTYSMS / TextOther
Email Address
example@example.com
Mobile Number
Please provide a valid phone number.
Home Number
Please provide a valid phone number.
TTY Number
Please provide a valid phone number.
Are you filing this grievance on behalf of someone else?*

YesNo
What is your relationship to the complainant?

Family Member / GuardianAdvocateOther
Primary type of disability*

Cognitive / Intellectual / DevelopmentalLearningMental / PsychiatricVisionHearingSeizureSpeechHIV / AIDSDiabetesOther
Section 2: Complaint Information
Nature of Complaint*

Denial of services or benefits/refusal to admitFailure to reasonably accommodatePhysical accessDigital accessSign language interpreter/assistive listeningService animalRetaliationOther
Who Your Complaint is Against*

County Employeeand / or County Department
Employee Name
Department*
Date of Incident*

MonthDayYear
Hour MinutesAM/PM Option
Location of Incident
Description of Complaint (please describe fully the nature of your complaint):
Section 3: Witness Information
Were there other witnesses to the Incident?

NoOneTwo
First Witness
Name of first witness
First witness job title (If an employee)
First witness phone, email, other contact information
Second Witness
Name of second witness
Second witness job title (If an employee)
Second witness phone, email, other contact information
Section 4: Documentation / Evidence
Please provide any documentation and list a describe evidence that directly supports your specific claim. You may also attach photographs or other files in support of your claims.
Documentation and Review of Evidence
File / Evidence Attachments

Cancelof
What actions would you want the County to take in response to your complaint?
Note: Parent or Legal Guardian may sign on behalf of minor child. Legal Guardian, Power of Attorney or equivalent may sign on behalf of adult – documentation is required.

By typing your name and submitting this form, you certify that to the best of your knowledge this information is true and correct.
Type your Name
Signed Date

MonthDayYear
Completed On: {signedDate}
Should be Empty:

Title II of the Americans with Disabilities Act Complaint/Grievance Form Larimer County, Colorado

Section 1: Name and Contact Info

Section 2: Complaint Information

Section 3: Witness Information

First Witness

Second Witness

Section 4: Documentation / Evidence