Rev 06082012
CITY OF GREENVILLE
AMERICANS WITH DISABILITIES ACT GRIEVANCE FORM
Today’s Date: ________________________________
Name of Grievant: ____________________________________________________________________________
Address of Grievant: __________________________________________________________________________
Telephone Number of Grievant: _________________________________________________________________
Name, Address, and Telephone Number of Alternate Contact Person:____________________________________
___________________________________________________________________________________________
Agency alleged to have denied access:
Department: ________________________________________________________________________________
Division: ____________________________________________________________________________________
Bureau or Office: _____________________________________________________________________________
Location: ___________________________________________________________________________________
I was denied access on: _______________________________[date]
Disability Statement:
My disability is:________________________________________________________________________________
____________________________________________________________________________________________
This problem is: temporary_______ permanent_______
I am seeking access to the following City of Greenville program or activity in which I haven’t been able to participate
because I need an accommodation:______________________________________________
Proposed Access or Accommodation:
The accommodation I seek:_______________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
I
Incident or Barrier:
Please describe the particular way in which you believe you have been denied the benefits of any services, program,
or activity or have otherwise been subjected to discrimination. Please specify dates, times, and places of incidents,
and names and/or positions of City employees involved, if any, as well as names, addresses and telephone numbers
of any eyewitnesses to any such incident. Attach additional pages if necessary. Include a description of the way in
which you feel access may be had to the benefits described above, or the way in which accommodation could be
provided to allow access.
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Fax this form to 864-298-2744 or email to mjank@greenvillesc.gov or mail to:
Mike Jank, ADA Coordinator
City of Greenville
Risk Management Division
PO Box 2207
Greenville, SC 29602
