Fillable ADA Complaint Form (Town of Culpeper)

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ADA Complaint Form (Town of Culpeper)

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TOWN OF CULPEPER GOVERNMENT
COMPLAINT PROCEDURE
UNDER THE AMERICAN WITH DISABILITIES ACT
The Town of Culpeper has established the following complaint procedure providing for
prompt and equitable resolution of complaints alleging any violation of the American
with Disabilities Act (ADA). This procedure may be used by anyone who wishes to file a
complaint alleging discrimination based upon disability in the Town’s provision of
services, activities, programs, or benefits. The Town’s Personnel Policies cover
employment-related complaints of discrimination. Complaints involving employment
issues will be referred to the appropriate Town department for review and investigation
in accordance with the Personnel Policies.
If your complaint refers to allegations of discrimination based on age, sex, race, religion,
national origin, color, and political affiliation you may file a Citizen Complaint Form for
Allegations of Discrimination by contacting staff from the Human Resources Department
at the number below.
Address Complaints To:
Town of Culpeper
ADA Coordinator
Human Resources Department
400 S. Main Street, Suite 300
Culpeper, VA 22701
(540) 829-8290 (phone)
(540) 829-8295 (fax)
HR@culpeperva.gov
1. A complaint should be filed in writing, contain the name, and address,
telephone number(s), and if possible, email address of the person filing it (i.e.
the complainant), a brief description of the alleged violation, including when
and where it occurred, and any request for reasonable accommodation
required by the complainant for the duration of the complaint process (e.g.
correspondence in alternate formats; sign language interpreters). For persons
with disabilities, assistance in completing the complaint is available. Call
(540) 829-8290 on any Town workday between the hours of 8:00 a.m. and
5:00 p.m. or email HR@culpeperva.gov. (A copy of a complaint form has
been attached for your use.)
2. A complaint should be filed as soon as possible, but no later than 60 days
after the complainant becomes aware of the alleged violation.
3. Upon receipt, the ADA Coordinator will provide the complainant with a
complaint procedure in a format accessible to the complainant.
4. The ADA Coordinator will contact and/or meet with the complainant within 15
calendar days of receipt of the complaint to discuss the complaint and
conduct whatever additional investigation of the complaint he or she
determines to be necessary.
5. The ADA Coordinator will respond to the complaint in writing, or where
appropriate, in a format accessible to the complainant, within 15 calendar
days of meeting with the complainant. This response will explain the Town’s
position and options to resolve the complaint, when appropriate.
6. If the complainant objects to the response, then he or she may appeal to the
ADA Coordinator within 15 calendar days after receiving the response. The
ADA Coordinators response becomes the Town’s final determination
respecting the complaint if the complainant does not so appeal.
7. Within 15 calendar days of receiving an appeal, the ADA Coordinator and/or
Town Manager will contact and/or meet with the complainant to discuss the
complainant’s objections to the ADA Coordinator’s initial response. If
determined to be necessary, an additional investigation will be conducted.
8. Within 15 calendar days after meeting with the complainant, the ADA
Coordinator and/or Town Manager will respond to the appeal in writing, or
where appropriate in a format accessible to the complainant. This response
will address each of the complainant’s objections to the ADA Coordinator’s
initial response. This response is the Town’s final determination respecting
the complaint.
9. The ADA Coordinator will retain all documents relating the a complaint for
three years after the date of the Town’s final determination respecting the
complaint.
10. Use of this complaint resolution procedure is not a prerequisite to the pursuit
of other legal remedies. A complainant therefore has the right to file a
complaint with the appropriate federal or state agency, including the U.S.
Department of Justice, at anytime throughout this process, or if the Town’s
final determination is not to his or her satisfaction.
For information about the ADA and how to file a complaint with the U.S.
Department of Justice, telephone 1-800-514-0301 (voice), 1-800-514-0383
(TTY), or go to the Internet site for the U.S. Department of Justice’s Civil
Rights Division.
11. This procedure shall be construed to protect the substantive rights of
interested persons regarding due process and to ensure that the Town of
Culpeper complies with laws, regulations and Town policies prohibiting
disability discrimination.
For additional information about this complaint procedure and the ADA generally,
please call (540) 829-8290 on any Town workday between the hours of 8:00 a.m. and
5:00 p.m. or email HR@culpeperva.gov. This complaint procedure can be provided in
an alternative format upon request.
TOWN OF CULPEPER GOVERNMENT
COMPLAINT FORM
UNDER THE AMERICAN WITH DISABILITIES ACT
1. Enter information about yourself.
First Name: ______________________ Last Name: __________________________
Address: __________________________________________________________
City: ________________________ State: ______________ Zip: ________________
Best time to Call You: ______________________________
Home Phone: ____________ Mobile Phone: ___________ Work Phone: __________
E-mail Address: ________________________________________________________
Who else can we contact if we cannot reach you?
Contact’s Name: ________________________ Contact’s Phone: _________________
Relationship to You: _____________________________________________________
2. Who was discriminated against?
____ Yourself
____ Someone else
(If the person discriminated against is 18 or older, we will need that person’s
signature before we can proceed with this complaint. Only the person harmed or
their legal guardian can file a complaint.)
If someone other than yourself, please include:
Injured person’s name: ________________________________________
Relationship to you: ___________________________
Address: ______________________________________________________________
City: ________________________ State: ______________ Zip: _________________
Daytime Phone: ______________________ Evening Phone: _____________________
3. Department Information
Department Name: ______________________________________________________
Name of Person(s) who discriminated against you:
1. Name: ________________________ Position/Title: ____________________
2. Name: ________________________ Position/Title: ____________________
3. Name: ________________________ Position/Title: ____________________
4. In the space provided below, please briefly describe each discriminatory action
separately. For each action, you need to provide the following information:
a. Date(s) the discriminatory action occurred;
b. Name(s) of the individual(s) who discriminated (include position, title);
c. Location of alleged violation;
d. What happened;
e. Witnesses, (if any);
f. Why you believe the discrimination was because of disability.
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
Do you have documents that you think will help us understand your
complaint? (If yes, you will be contacted with instructions for submitting this
information. Do not send original documents.)
____Yes ____No
5. What solution are you seeking?
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
______________________________________________________________
This complaint form can be provided in an alternative format upon request. Please contact the Town of
Culpeper Human Resources Department at (540) 829-8290 or HR@culpeperva.gov.
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ADA Complaint Form (Town of Culpeper)

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Completed 15 July 2020

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