Fillable City of Round Rock ADA Grievance Form Title (City of Round Rock, Texas)

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City of Round Rock ADA Grievance Form Title (City of Round Rock, Texas)

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City of Round Rock
ADA Grievance Form
Title II of the Americans with Disabilities Act Section 504 of the Rehabilitation Act of 1973
Instructions: Please fill out this form completely. Sign and send it to the address at the bottom of the
page. Incomplete forms will not be processed.
Name:
Address:
City:
State: Zip:
Phone: ( )
E‐mail:
Grievance Information
Address:
Time/Date:
Please provide a complete description of your grievance (attach additional pages as needed):
Signature: Date:
Please return to: ADA Transition Plan Coordinator, 2008 Enterprise Drive, Round Rock, Texas 78664
For Office Use Only
Facilities outside City jurisdiction will be forwarded to the appropriate entity by the City of Round Rock.
File #: Date Received: Received By:
Notes:
Reviewer Name: Title: ADA Plan Coordinator
Signature: Date:
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City of Round Rock ADA Grievance Form Title (City of Round Rock, Texas)

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Completed 16 July 2020

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