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Grievance Procedure April 2019 Fillable (City of Oakland)

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ADA Grievance Form Rev. 4/2019 1
CITY OF OAKLAND
ADA Programs Division PHONE (510) 238-5219
One Frank Ogawa Plaza, 11
th
Floor FAX (510) 238-3304
Oakland, CA 94612 711 for CA Relay Service
City of Oakland
Grievance Procedure for Complaints Arising Under Title II of the
Americans with Disabilities Act (ADA)
(Excluding Employment)
This Grievance Procedure is established to meet the requirements of Title II of the Americans
with Disabilities Act of 1990 ("ADA"). 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 Oakland (“the City”). Complaints of disability discrimination involving
other public entities or private businesses will not be accepted by the ADA Programs
Division. Please note: do not use this form to file a complaint alleging employment disability
discrimination against City employees or job applicants. Instead, please contact the Equal
Opportunity Programs Division at 510-238-6468 or by email at: amccullough@oaklandca.gov.
Filing a grievance: Please complete this form as fully as possible. The complaint should be
submitted by the individual alleging discrimination on the basis of disability or an authorized
representative as soon as possible but no later than 60 calendar days after the alleged
discrimination. If you require this form in an alternative format, or need other assistance to
submit your complaint, then contact the ADA Programs Division at 510-238-5219 or by e-mail at
adaprograms@oaklandca.gov.
City response to grievance: Within 10 business days after receipt of the complaint, the ADA
Coordinator, or a designee, will contact the complainant or representative to discuss the
complaint and possible resolutions. Within 30 business days of receipt of the complaint, unless
the period is extended by agreement with the complainant or representative, the ADA
Coordinator, or designee, will respond in writing, in a format accessible to the complainant. The
response will explain the position of the City and, what actions if any the City will take to resolve
the complaint.
Appeal: If the response by the ADA Coordinator, or designee, does not satisfactorily resolve the
issue, the complainant and/or a designee may appeal the decision within 10 business days after
receipt of the response to the City Administrator. The City ADA Coordinator’s findings on
appeals from residential on-street disabled parking zone, curb ramp, or sidewalk repair denials
are final and not appealable.
City response to appeal: Within 10 business days after receipt of the appeal, the City
Administrator, or a designee, will interview the complainant to discuss the complaint and
ADA Grievance Form Rev. 4/2019 2
possible resolutions. Within 20 business days after the interview, the complainant will receive a
response either affirming or modifying the determination of the City ADA Coordinator.
All documented complaints received by the ADA Coordinator, appeals to the City Administrator,
and responses from these offices will be retained by the City of Oakland for at least three years.
The City will not retaliate against you for filing a grievance. Any form of retaliation related to the
filing of this complaint is prohibited and should be reported immediately to the ADA Coordinator.
Please be advised that some of the information you supply on this complaint form may be
subject to public disclosure under the California Public Records Act. However, the City will
make every reasonable effort to ensure that confidentiality is maintained throughout the
complaint, investigation, and corrective action process, to the extent consistent with the law.
Additionally, in the event that the City decides that your complaint requires further investigation,
witnesses may be interviewed, and the accused party/parties will be given an opportunity to
respond to your allegations.
Please submit your ADA grievance form to:
ADA Coordinator
ADA Programs Division
One Frank Ogawa Plaza, 11
th
Floor
Oakland, CA 94612
Voice: 510-238-5219
CA Relay Service: 711
Email: adaprograms@oaklandca.gov
Please note: If you have made a request for a curb ramp, sidewalk repair, or disabled parking
zone and are not satisfied with the results, you may appeal the denial using this grievance
process. The ADA Coordinator’s response to your appeal will be final.
If you have not yet made a request, you must do so first.
To make a request for a Sidewalk Repair or Curb Ramp, you may click here for an application.
To request a Disabled Parking Zone, you may click here for an application.
You may also make a request by calling 311 or 510-615-5566 or by sending an email to
oak311@oaklandca.gov
.
ADA Grievance Form Rev. 4/2019 3
City of Oakland
Grievance Form
Complaint of Access Violation or Discrimination on Basis of Disability
Please fill out the information below as fully as possible. Feel free to use the back of these
pages or additional pages if necessary.
1. What is the nature of your complaint?
☐Sidewalk Repair Denial ☐Curb Ramp Denial ☐Disabled Parking Zone Denial
☐Other ADA issue: (Briefly describe)
2. Your information
Name:
Address:
City: State: Zip:
Telephone numbers: Home: Work:
Cell:
Email:
Check all preferred methods of communication:
☐ Voice telephone ☐ 711 CA Relay Service ☐ Email ☐ U.S. Mail
Other:
What is your relationship to the complainant? ☐ Self ☐ Family member/guardian
☐ Advocate ☐ Other:
3. Are you filing this grievance on behalf of someone else?
If so, please enter their information here:
Name:
Address:
City: State: Zip:
Telephone numbers: Home: Work:
Cell:
Email:
Check all preferred methods of communication:
☐ Voice telephone ☐ 711 CA Relay Service ☐ Email ☐ U.S. Mail
Other:
City employees and job applicants wishing to file a complaint of disability discrimination should contact the
Equal Opportunity Programs Division at 510-238-3500 (voice); 510-238-4749 (fax). Do not use this form.
The City’s Personnel Policy governs employment-related complaints of disability discrimination.
ADA Grievance Form Rev. 4/2019 4
4. Who Your Complaint Is Against
☐City Employee and/or ☐City Department
Name:
Job title:
City Department:
Address:
Telephone number:
5. Complaint Information
Date of incident:
Time of incident:
Location of incident:
6. Description of complaint
Please describe fully the nature of your complaint.
ADA Grievance Form Rev. 4/2019 5
7. Witness Information (If other people witnessed the incident, please list their names and
contact information here.)
Name:
Job title and department (if City employee):
Address:
Telephone number/email/other contact information:
Name:
Job title and department (if City employee):
Address:
Telephone number/email/other contact information:
8. Evidence and Documentation
Please list and provide any physical evidence, written or recorded documents, or any other
information that directly supports your specific claim. You may also attach photographs or other
documents in support of your claims.
9. What actions would you want the City to take in response to your complaint?
10. Signature: __________________________________________ Date: ______________
Please submit your ADA grievance form to:
ADA Coordinator
ADA Programs Division
One Frank Ogawa Plaza, 11
th
Floor
Oakland, CA 94612
Voice: 510-238-5219
CA Relay Service: 711
Email: adaprograms@oaklandca.gov
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Completed 19 July 2020

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