ADA Complaint Form

ADA Complaint Form
In compliance with the Americans with Disabilities Act of 1990, The Arc of the Quad Cities Area operates all its programs and provides public transportation services without regard to disability. Anyone who believes they have been subject to unlawful discriminatory practice by The Arc of the Quad Cities Area due to a disability has the right to file an ADA complaint. ADA complaints must be filed within 180 days from the date of the alleged discrimination.

The following information is necessary to assist us in processing your complaint. If you require any assistance in completing this form, please contact The Arc of the Quad Cities Area Administrative Office by calling (309)786-6474. The completed form must be returned to The Arc of the Quad Cities Area, Attn: ADA Customer Service, 736 37th Avenue, Rock Island, Illinois, 61201. Faxed, emailed, or electronically transmitted forms are not accepted. Hand delivery is needed to make sure the complaint is filed within the statutory deadline.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Person(s) discriminated against (If someone other than complainant): blanks
Please describe the alleged discrimination incident as accurately as possible, including names, dates, and times. Provide the names and title of all The Arc of Quad Cities Area employees involved (if available). Explain what happened and whom you believe was responsible.
Have you filed a complaint with any other federal, state, or local agencies?
Agency
Agency Contact Name
Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Agency
Agency Contact Name
Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I affirm that I have read the above charge and that it is true to the best of my knowledge, information and belief.
Complainant's Signature
Name

First NameLast Name
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: