"Americans With Disabilities Act (Ada) Grievance/Complaint Form" - South Dakota

Americans With Disabilities Act (Ada) Grievance/Complaint Form is a legal document that was released by the South Dakota Department of Transportation - a government authority operating within South Dakota.

Form Details:

  • The latest edition currently provided by the South Dakota Department of Transportation;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the South Dakota Department of Transportation.

ADVERTISEMENT
ADVERTISEMENT

Download "Americans With Disabilities Act (Ada) Grievance/Complaint Form" - South Dakota

Download PDF

Fill PDF online

Rate (4.6 / 5) 30 votes
Page background image
Americans with
Disabilities Act (ADA)
Grievance/Complaint
Form
Personal Information
NAME:____________________________________________________________________
Last
First
MI
ADDRESS:____________________________ CITY:____________________ STATE:____
ZIP:________ PHONE: ( ____ ) _____ - _______ EMAIL:___________________________
Organization (if any)
NAME:____________________________________________________________________
ADDRESS:____________________________ CITY:____________________ STATE:____
ZIP:________ PHONE: ( ____ ) _____ - _______ EMAIL:___________________________
Location of Physical Barriers (if applicable)
CITY:____________________ HIGHWAY / INTERSTATE #:_________
STREET INTERSECTION: ____________________________________________________
NEARBY LANDMARKS OR BUSINESSES:_____________________________________
Report of Incident of Discrimination under the ADA (if applicable)
DATE: ___ / ___ / ______ PERSON(S) INVOLVED:_______________________________
WITNESSES:__________________________________ PHONE: ( ____ ) _____ - _______
Please describe any alleged incidents of discrimination:______________________________
__________________________________________________________________________
For Transit Related Grievances ( if applicable)
NAME OF TRANSIT PROVIDER:________________________________________________
CITY: __________________________ STAFF INVOLVED: _________________________
Please describe any alleged incidents of discrimination: _______________________________
_____________________________________________________________________________
Americans with
Disabilities Act (ADA)
Grievance/Complaint
Form
Personal Information
NAME:____________________________________________________________________
Last
First
MI
ADDRESS:____________________________ CITY:____________________ STATE:____
ZIP:________ PHONE: ( ____ ) _____ - _______ EMAIL:___________________________
Organization (if any)
NAME:____________________________________________________________________
ADDRESS:____________________________ CITY:____________________ STATE:____
ZIP:________ PHONE: ( ____ ) _____ - _______ EMAIL:___________________________
Location of Physical Barriers (if applicable)
CITY:____________________ HIGHWAY / INTERSTATE #:_________
STREET INTERSECTION: ____________________________________________________
NEARBY LANDMARKS OR BUSINESSES:_____________________________________
Report of Incident of Discrimination under the ADA (if applicable)
DATE: ___ / ___ / ______ PERSON(S) INVOLVED:_______________________________
WITNESSES:__________________________________ PHONE: ( ____ ) _____ - _______
Please describe any alleged incidents of discrimination:______________________________
__________________________________________________________________________
For Transit Related Grievances ( if applicable)
NAME OF TRANSIT PROVIDER:________________________________________________
CITY: __________________________ STAFF INVOLVED: _________________________
Please describe any alleged incidents of discrimination: _______________________________
_____________________________________________________________________________
Please list any suggested changes or improvements to achieve accessibility:______________
__________________________________________________________ ______
_________________________________________________________________
_________ ______________________________________________________
Mail to:
Department of Transportation
ATTN: ADA Coordinator
Office of Legal Counsel
700 East Broadway Avenue
Pierre, SD 57501-2586
Phone:
605-773-3540
FAX:
605-773-4442
Email:
june.hansen@state.sd.us
Telecommunication Device for the Deaf: 1-800-877-1113
Page of 2