Action Center / ADA Grievance / / Jasper, IN

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ADA Grievance

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Americans with Disabilities Act Grievance Form

This Grievance Procedure is established to meet the requirements 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.

Please fill out the fields below

* Denotes a required field

Person filling out this form

Full Name*

Address*

City*

State*

ZIP*

Zip-Zip +4
Second portion of ZIP Code is optional.

Contact Phone Number*

Phone Area Code-Phone 3-Phone 4 ext Extension

Email Address

Person(s) Discriminated Against (if other than the complainant)

Full Name

Address

City

State

ZIP

Zip-Zip +4
Second portion of ZIP Code is optional.

Telephone

Phone Area Code-Phone 3-Phone 4 ext Extension

Please Do Not Complete The Following Field

Discriminatory Incident

When did the discrimination occur?*

MonthDay Year,

Description*

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The City of Jasper, Indiana

Action Center

ADA Grievance

Person filling out this form

Person(s) Discriminated Against (if other than the complainant)

Discriminatory Incident

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