4. A. Have you filed a claim regarding this complaint with a federal, state or local government agency? Yes No
B. Have you hired an attorney with respect to the allegations in the complaint? Yes No
C. Have you instituted a legal suit or court action regarding this complaint? Yes No
5. This complaint form was completed by: ADA Coordinator
Please use this form to file a complaint based on disability in the provision of services, activities, programs or benefits.
Please submit this form to the ADA Coordinator, LaShanna S. Frasier; you may find contact Ms. Frasier at
LaShanna.Frasier@health.ny.gov or (518) 473-7883.
Name: Home Phone:
Home Address: Email:
1. Your claim is made against:
2. Location(s) and date(s) of the circumstances giving rise to your complaint:
Are the circumstances of your complaint continuing? Yes No
3. Please describe the alleged denial of services, activities, programs or benefits and your reason(s) for concluding that the conduct
was discriminatory. Please include the name(s) of witnesses, if any, and attach supporting data, if available.
Americans with Disabilities Act Complaint Form
NEW YORK STATE DEPARTMENT OF HEALTH
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