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Revised 02/07/19
AMERICANS WITH DISABILITIES ACT (TITLE II) COMPLAINT FORM
Knox County ensures that no person or groups of persons shall, on the grounds of race, color, sex, religion, national
origin, age, disability, retaliation or genetic information, be excluded from participation in, be denied the benefits of, or be
otherwise subjected to discrimination under any and all programs, services, or activities administered, its recipients, sub-
recipients, and contractors. To request an accommodation and/or an alternate format, please contact Cindy Pionke,
Strategic Facilities Engineer and ADA/504 Coordinator at 865-215-3641, or TTY 865-215-2497.
Date of Filing:
Name:
Address:
City, State, Zip Code:
Work Phone:
Home Phone:
Email Address:
Date of Alleged Incident:
Indicate below the person(s) who you believe discriminated against you:
Name(s):
Work Location:
Work Phone:
Please provide a detailed description of the alleged incidence of discrimination. If there are any
witnesses, please provide their contact information. Attach additional pages as necessary.
Please provide a suggested detailed plan or remedy for this complaint. Attach additional pages as
necessary.
