Basic Data Entry Forms

ADA Complaint Form






Use this form to notify us of a matter of noncompliance with the Americans with Disabilities Act.

This form has been optimized for accessibility to persons with physical impairments.

* indicates required fields

(ML) Denotes multi-line text boxes for screen readers.

Today's Date*
Your Full Name*
Street Address (ML)*
City or Town*
State*
Zip Code*
Telephone or TTY*
Email Address*
Type of Violation:
Name of Place were alleged violation exists or occured (ML)*
Location of Alleged Violation (ML)*
Please describe the ADA violation (ML)*
If applicable, date of alleged violation
If applicable, time of violation (like 23:00 for 11 PM)
Have efforts been made to resolve this complaint through any other means?*	YesNo
If Yes, what is the status of the complaint? (ML)
Has the complaint been filed with any Federal, state, or local civil rights agency or court?*	YesNo

If yes, please provide contact details including: Agency, Person, Address, Phone, Date Filed (ML)
If available, upload a photo of the violation.	File Size: 1KB Maximum File Types: .jpg .jpeg .jpe .gif .doc .pdf .zip

	Also send me a copy
Submit
* Required