Disability Services Request and Grievance Form
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
E-mail
*
What form do you want?
Services Request
Submit a Grievance/Problem/Suggestion
Services Request
Type of Service Requested
*
Assisted Listening Device Location
*
Choose an option
House Chamber
House Committee Room (HCR) 1
HCR-2
HCR-3
HCR-4
HCR-5
HCR-6
Senate Chamber
Senate Committee Room (SCR) A
SCR-C
SCR-E
SCR-F
Senate Hainkel Room
Choose an option
Braille Print & Large Type Print
*
Date Service Needed
*
-
Month
-
Day
Year
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Submit
Grievance-Problem-Suggestion related to disability services of the LA House of Representatives
Check all that apply
*
Date of incident
-
Month
-
Day
Year
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Location of incident
Choose an option
House Committee Room 1 (HCR-1)
HCR-2
HCR-3
HCR-4
HCR-5
HCR-6
House Chamber
Senate Committee Room A (SCR-A)
SCR-C
SCR-E
SCR-F
Hainkel Room
Senate Chamber
Description of grievance, problem or suggestion
*
Submit
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