Fillable Ada-grievance - ADA Grievance Form (10.17.15)

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Ada-grievance - ADA Grievance Form (10.17.15)

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ADA#Grievance#Form_English October#2015
City%of%Fort%Worth%
ADA%Grievance%Form%
Title&II&of&the&Americans&with&Disabilities&Act&Section&504&of&the&Rehabilitation&Act&of&1973&
Instruct io ns :% Please#complete#this#form#in#its#entirety.##Failure#to#provide#all#requested#information#
may#cause#delay#in#response.##Please#mail#this#form#to#ADA#Coordinator,#City#of#Fort#Worth,#908#Monroe#
Street,#Fort#Worth,#Texas,#76102,#or#email#it#to #ada@ fortworthtexas.gov%
Name:#____________________________________________________________________________#
Address:#__________________________________________________________________________#
#State:#_____# Zip:#_____________#
City:#___________________________________##
Phone:#__________________________#
Email:#_______________________________#
Location#of#issue#giving#r ise #to #g rie va n ce #(p le as e #p ro vid e #an #a ddress#if#po ss ib le ):#
___________________________________________________________________________________#
Time/date#of#issue#giving#rise#to#grievance#(if#applicable):____________________________________#
Please#provide#information#that#will#help#us#better#understand#your#concern:#
___________________________________________________________________________________#
___________________________________________________________________________________#
___________________________________________________________________________________#
___________________________________________________________________________________#
___________________________________________________________________________________#
___________________________________________________________________________________#
Please#attach#additional#pages#as#needed.#
Signature:#______________________________________# Date:#__________________________#
____________________________________________________________________________________#
For#ADA#Coordinator#Office#use:#
File#No.#_______________#
Date#Received:##___________________# # Received#by:#___________________#
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________#
Reviewer#Name:#_____________________________________#Title:#_____________________________#
Signature:#__________________________________________#Date:#_____________________________#
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Ada-grievance - ADA Grievance Form (10.17.15)

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Completed 12 July 2020

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