CITY OF LAKE FOREST
TITLE II OF THE AMERICANS WITH DISABILITIES ACT
GRIEVANCE FORM
Instructions: Please fill out this form completely in black ink or type. Sign and return to ADA
Coordinator, ATTN: Shelly Cisneros, Human Resources Manager,
100 Civic Center Drive, Lake Forest, CA 92630. This form is optional and provided for your
convenience.
Today’s Date:
Grievant Name:
Address:
Email Address:
Telephone: Work: Cell:
If a legally authorized representative is filing the grievance on your behalf, his/her name, address
and telephone number must also be included:
Name:
Address:
Email Address:
Telephone: Work: Cell:
Date of Incident: Time of Incident:
Location or address of incident:
Describe your grievance:
If the incident(s) involved a City of Lake Forest employee(s), his/her name(s):
The name(s) and contact information of witnesses:
If your grievance is being filed on behalf of another person or a group of people, all of the
grievant(s) should be described or identified by name, if possible.
State your requested remedy to your grievance:
Grievant:
Date:
Legally Authorized Representative:
Date:
