"Americans With Disabilities Act Grievance Complaint Form" - City of Rancho Mirage, California

Americans With Disabilities Act Grievance Complaint Form is a legal document that was released by the Administrative Services Department - City of Rancho Mirage, California - a government authority operating within California. The form may be used strictly within City of Rancho Mirage.

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AMERICANS WITH DISABILITIES ACT
1
GRIEVANCE COMPLAINT FORM
CITY OF RANCHO MIRAGE
RANCHO MIRAGE REDEVELOPMENT SUCCESSOR AGENCY
RANCHO MIRAGE HOUSING AUTHORITY
RANCHO MIRAGE LIBRARY
The City of Rancho Mirage and its affiliated agencies including but not limited to the Rancho
Mirage Redevelopment Successor Agency, Rancho Mirage Housing Authority and Rancho
Mirage Library (collectively referred to as the (“City”) is committed to providing equal access for
people with disabilities to take part in and benefit from any programs, services and activities
provided by the City.
The purpose of this Grievance Complaint Form is to ensure that the City promptly addresses
any programs, concerns, complaints or conflicts related to Americans with Disabilities Act
(“ADA”) compliance.
Please type or print in blue or black ink and return the completed form to:
Charles Nesbit, ADA/504 Coordinator
City of Rancho Mirage
69-825 Highway 111
Rancho Mirage, California 92270
Telephone: (760) 323-0561 EXT. 523
Facsimile:
(760) 323-3792
California Relay Service 7-1-1 (for TTY users)
Email Address:
charlesn@ranchomirageca.gov
Name
Address
Complainant
Telephone
Facsimile
Email Address
Name
Authorized
Address
Representative,
Telephone
if any
Facsimile
Email Address
1.
Please describe the alleged incident or access violation in detail. Attach additional
pages if necessary.
1
In lieu of this Grievance Complaint form, complaints may be submitted in alternate formats to the ADA
Coordinator to accommodate any complainant who is a qualified person or persons with a disability.
AMERICANS WITH DISABILITIES ACT
1
GRIEVANCE COMPLAINT FORM
CITY OF RANCHO MIRAGE
RANCHO MIRAGE REDEVELOPMENT SUCCESSOR AGENCY
RANCHO MIRAGE HOUSING AUTHORITY
RANCHO MIRAGE LIBRARY
The City of Rancho Mirage and its affiliated agencies including but not limited to the Rancho
Mirage Redevelopment Successor Agency, Rancho Mirage Housing Authority and Rancho
Mirage Library (collectively referred to as the (“City”) is committed to providing equal access for
people with disabilities to take part in and benefit from any programs, services and activities
provided by the City.
The purpose of this Grievance Complaint Form is to ensure that the City promptly addresses
any programs, concerns, complaints or conflicts related to Americans with Disabilities Act
(“ADA”) compliance.
Please type or print in blue or black ink and return the completed form to:
Charles Nesbit, ADA/504 Coordinator
City of Rancho Mirage
69-825 Highway 111
Rancho Mirage, California 92270
Telephone: (760) 323-0561 EXT. 523
Facsimile:
(760) 323-3792
California Relay Service 7-1-1 (for TTY users)
Email Address:
charlesn@ranchomirageca.gov
Name
Address
Complainant
Telephone
Facsimile
Email Address
Name
Authorized
Address
Representative,
Telephone
if any
Facsimile
Email Address
1.
Please describe the alleged incident or access violation in detail. Attach additional
pages if necessary.
1
In lieu of this Grievance Complaint form, complaints may be submitted in alternate formats to the ADA
Coordinator to accommodate any complainant who is a qualified person or persons with a disability.
2.
Please give the date(2), time(s) and location(s) of the alleged incident(s) or
observation(s) of access violation(s):
3. If the incident involved a City employee(s), please provide his or her name(s), if known:
4. Please provide the name and contact information, if known, of any witnesses to the
alleged incident or access violation:
5. If this complaint is filed on behalf of another person or group of people, please provide
the names and contact information of all the complainants, if possible:
6. Please specify the remedy or action you seek to correct and/or resolve the alleged
incident or access violation:
7. Please provide any other relevant information regarding your grievance complaint.
SIGNATURE: _______________________________________________________
NAME:
_______________________________________________________
DATE:
_______________________________________________________
J/brittw/ADA/Grievance Complaint Form
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