"Americans With Disabilities Act (Ada) Grievance Form" - California

Americans With Disabilities Act (Ada) Grievance Form is a legal document that was released by the California Department of General Services - a government authority operating within California.

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STATE OF CALIFORNIA
DEPARTMENT OF GENERAL SERVICES
AMERICANS WITH DISABILITIES ACT (ADA)
GRIEVANCE FORM
INSTRUCTIONS
This is a printable form. Simply complete, print, and send to: Department of General Services,
Att’n: ADA Coordinator, P.O. Box 989052, West Sacramento, CA 95798-9052
COMPLAINANT INFORMATION
NAME
ADDRESS
ZIP CODE
CITY
STATE
HOME PHONE (include area code)
BUSINESS PHONE (include area code)
PERSON ALLEGING ADA VIOLATION (if other than complainant)
NAME
ADDRESS
CITY
STATE
ZIP CODE
HOME PHONE (include area code)
BUSINESS PHONE (include area code)
INFORMATION ON ALLEGED VIOLATION
DATE ALLEGED VIOLATION OCCURRED
DESCRIPTION OF ALLEGED VIOLATION
STATE OF CALIFORNIA
DEPARTMENT OF GENERAL SERVICES
AMERICANS WITH DISABILITIES ACT (ADA)
GRIEVANCE FORM
INSTRUCTIONS
This is a printable form. Simply complete, print, and send to: Department of General Services,
Att’n: ADA Coordinator, P.O. Box 989052, West Sacramento, CA 95798-9052
COMPLAINANT INFORMATION
NAME
ADDRESS
ZIP CODE
CITY
STATE
HOME PHONE (include area code)
BUSINESS PHONE (include area code)
PERSON ALLEGING ADA VIOLATION (if other than complainant)
NAME
ADDRESS
CITY
STATE
ZIP CODE
HOME PHONE (include area code)
BUSINESS PHONE (include area code)
INFORMATION ON ALLEGED VIOLATION
DATE ALLEGED VIOLATION OCCURRED
DESCRIPTION OF ALLEGED VIOLATION
REQUESTED REMEDY
HAS THIS COMPLAINT BEEN FILED WITH THE RESPONSIBLE FEDERAL ENFORCEMENT AGENCY,
U.S. DEPARTMENT OF JUSTICE, OR COURT?
YES
NO
COMPLETE THE FOLLOWING IF YOU ANSWERED
“YES” TO THE PREVIOUS QUESTION
AGENCY OR COURT
CONTACT PERSON
ADDRESS
CITY
STATE
ZIP CODE
PHONE (include area code)
DATE FILED
OTHER COMMENTS
SIGNATURE
DATE
PRINT
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