Fillable Form 9477 ADA Complaint Form (City of Brighton)

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Form 9477 ADA Complaint Form (City of Brighton)

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City of Brighton
500 South 4
th
Avenue
Brighton, CO 80601
303-655-2000 Office
www.brightonco.gov
Email: ada@brightonco.gov
ADA Complaint Form
If you feel that you have not been able to access a City of Brighton program or service because of lack of
accessibility, or that you have been discriminated against because of your disability, please fill out this form
completely in print or type. Sign and return to the ADA Coordinator via email, fax, mail or in person within
30 days of the alleged incident. Complaints are processed as quickly as possible – please refer to the ADA
Complaint Procedure for more information. If you require assistance completing this form, please contact
the ADA Coordinator.
Complainant Information:
FIRST NAME LAST NAME
________________________________ ____________________________________
DAYTIME PHONE (Please include area code) ALTERNATE PHONE (Please include area code)
________________________________ ____________________________________
MAILING ADDRESS CITY
________________________________ ____________________________________
STATE ZIP CODE EMAIL ADDRESS (If available)
____________ _______________ ____________________________________
How would you like us to contact you?
Email Mail Telephone Other (specify) _________________________
Who do you believe discriminated against you?
NAME OF PERSON(S) COMPLAINT IS ABOUT:
______________________________________
DATE(S) DISCRIMINATION OCCURRED:
________________________________________
DEPARTMENT/OFFICE:
______________________________________
PHONE (Please include area code):
________________________________________
BUILDING/LOCATION OF WHERE INCIDENT(S) OCCURRED:
_________________________________________________________________________________
Describe briefly the reason for the complaint. How and why do you believe that you have
been (or someone else has been) discriminated against? Please be as specific as possible.
Attach additional documentation if needed.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Have efforts been made to resolve this complaint directly through the applicable
department/office?
Yes No
If yes, what is the status of the complaint?
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Has the complaint been filed with or do you intend to file the complaint with any Federal,
State, or local civil rights agency or court?
Yes, a complaint has been filed Yes, I intend to file a complaint No
If yes:
Agency or Court name
_______________________________________________
Date filed
_____________________________
Mailing Address, City, State, ZIP Code
_______________________________________________
Agency contact
_____________________________
Agency phone number | Other phone number
_______________________________________________
Email address
_____________________________
Please sign and date this request. You do not need to sign if submitting this form by email,
just type your name.
Signature: _________________________________
Date: ____________________
Action taken:
Date received:
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
ADA Coordinator Signature: _________________________
Date: _______________
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Form 9477 ADA Complaint Form (City of Brighton)

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Completed 14 July 2020

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