Fillable Complaint Grievance Procedure And Form (City of El Mirage)

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Complaint Grievance Procedure And Form (City of El Mirage)

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City of El Mirage
Grievance Procedure under the Americans with Disabilities Act (ADA)
This Grievance Procedure is established to meet the requirements of the Americans with Disabilities Act of
1990. It may be used by anyone who wishes to file a complaint alleging discrimination on the basis of
disability in the provision of services, activities, programs, or benefits by the City of El Mirage. The
City’s Personnel Policy governs employment-related complaints of disability discrimination.
The complaint should be in writing and contain information about the alleged discrimination such as name,
address, phone number of complainant and location, date, and description of the problem (A grievance form
is attached for convenience). Alternative means of filing complaints, such as personal interviews or a tape
recording of the complaint will be made available for persons with disabilities upon request.
The complaint should be submitted by the grievant and/or his/her designee as soon as possible, but no later
than 60 calendar days after the alleged violation, to:
City of El Mirage
Community Development Department
ADA Coordinator
10000 N. El Mirage Road
El Mirage, AZ 85335
Within 15 calendar days after receipt of the complaint, the ADA Coordinator or his/her designee will meet
with the complainant to discuss the complaint and the possible resolutions. Within 15 calendar days of the
meeting, the ADA Coordinator or his/her designee will respond in writing, and where appropriate, in format
accessible to the complainant, such as large print or audio tape. The response will explain the position of the
City and offer options for substantive resolution of the complaint.
If the response by the ADA Coordinator or his/her designee does not satisfactorily resolve the issue, the
complainant and/or his/her designee may appeal the decision within 15 calendar days after receipt of the
response to the City Engineer or his/her designee.
Within 15 calendar days after receipt of the appeal, the City Engineer or his/her designee will meet with the
complainant to discuss the complaint and possible resolutions. Within 15 calendar days after the meeting, the
City Engineer or his/her designee will respond in writing, and, where appropriate, in a format accessible to the
complainant, with a final resolution of the complaint.
All written complaints received by the ADA Coordinator or his/her designee, appeals to the City Engineer
or his/her designee, and responses from these two offices will be retained by the City for at least three years.
City of El Mirage
ADA Complaint / Grievance Form
Complainant Name: _________________________________________________________________________
Person Preparing Complaint (If different from Complainant): ________________________________________
Relationship to Complainant (If different from Complainant): ________________________________________
Street Address & Apartment Number: ___________________________________________________________
City: ____________________________________________ State: _______________ Zip: ______________
Phone Number: _______________________ Email: ______________________________________________
Preferred method of contact: Phone Email
Please provide a complete description of the specific complaint or grievance:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please specify any location(s) related to the complaint or grievance (if applicable):
__________________________________________________________________________________________
__________________________________________________________________________________________
Please state what you think should be done to resolve the complaint or grievance:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
(Attach additional pages, if necessary.)
Please do not contact me personally.
Signature: _______________________________________________ Date: ___________________________
Return to: City of El Mirage, Community Development Department, ADA Coordinator
10000 N. El Mirage Road, El Mirage, AZ 85335
Upon request, reasonable accommodation will be provided in completing this form or copies of the form will
be provided in alternative formats. Contact the ADA Coordinator at the address listed above or via telephone at
(623) 876-2977.
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Completed 16 July 2020

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