Title II of the Americans with Disabilities Act Complaint/Grievance Form Archuleta County

Title II of the Americans with Disabilities Act Complaint/Grievance Form Archuleta County

All fields marked with * are required and must be filled.
Name and Contact Info:
Full Name

First NameLast Name
Full Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail

Confirmation Emailexample@example.com
Preferred Method of Communication
Are you filling out this grievance on behalf of someone else?
Optional: Explain the cognitive function which was impacted and any other pertinent information regarding your complaint.
Section 2: Complaint Information
Who is Your Complaint Against
Department
Date of incident
Location of Incident
Description of Complaint (please describe nature of complaint)
Section 3: Witness Information
Were there other witnesses to the incident?
Section 4: Documentation / Evidence
Please provide any documentation and list or describe any evidence which directly supports your specific claim.
Upload File
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.
Please type your name
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