Fillable City of Diamond Bar Americans with Disabilities Act (City of Diamond Bar)

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City of Diamond Bar Americans with Disabilities Act (City of Diamond Bar)

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The City of Diamond Bar Americans with Disabilities Act (City of Diamond Bar) form is 3 pages long and contains:

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File type: PDF

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1
City of Diamond Bar
Americans with Disabilities Act and
Section 504 of the Rehabilitation Act of 1973
Grievance Form
Instructions: Please fill out this form completely. A printed or typed response is
recommended. Sign and return to the address on last page by email, fax, mail or in
person. If you need an accommodation to complete or submit this form, please contact
the ADA Coordinator.
1. Complainant Name:
Address:
City, State and Zip Code:
Telephone:
2. Person Discriminated Against:
Address:
City, State, and Zip Code:
Telephone:
3. Department or person which you believe has discriminated (if known):
Name:
Address:
City, State and Zip Code:
2
Telephone Number:
When did the discrimination occur? (Date/time/location)
3. Describe the acts of discrimination providing the name(s) where possible of the
individuals who discriminated:
4. Have efforts been made to resolve this complaint? Yes No
If yes, what efforts have been taken and what is the status of the grievance?
5. Has the complaint been filed with another bureau, such as the Department of Justice
or any other Federal, State, or local civil rights agency or court?
Yes No
If yes:
Agency or Court:
Contact Person:
Address:
City, State, and Zip Code:
3
Telephone Number: Date Filed:
6. Do you intend to file with another agency or court? Yes No
If yes:
Agency or Court:
Contact Person:
Address:
City, State, and Zip Code:
7. Additional comments or information:
Signature: Date:
Return to:
City of Diamond Bar
Attn: ADA Coordinator
21810 Copley Drive
Diamond Bar, CA 91765
California Relay Service: dial 711
REFERENCES
Americans with Disabilities Act Title II Regulations, Department of Justice 28 CFR Part
35 §35.107
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City of Diamond Bar Americans with Disabilities Act (City of Diamond Bar)

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Completed 3 August 2020

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