"Americans With Disabilities Act (Ada) Complaint Procedures Form" - Henry County, Georgia (United States)

Americans With Disabilities Act (Ada) Complaint Procedures Form is a legal document that was released by the Transit Department - Henry County, Georgia - a government authority operating within Georgia (United States). The form may be used strictly within Henry County.

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H
C
ENRY
OUNTY
A
D
A
(ADA)
MERICANS WITH
ISABILITIES
CT
C
P
F
OMPLAINT
ROCEDURES
ORM
T
P
C
YPE OR
RINT
LEARLY
Complaints about the accessibility of the Henry County Transit system or service, or complaints regarding believes of discrimination
because of a disability, may filed with the Henry County Transit Department. Complainants must provide all facts and circumstances
surrounding the issue or complaint so the incident can be fully investigated. For assistance with this form, or if information is needed
in another language, call 770-288-7433.
C
F
M
S
O
F
:
OMPLETED
ORMS
UST BE
UBMITTED TO
NE OF THE
OLLOWING
Henry County Transit Department
Email
tsalters@co.henry.ga.us
Mail / In Person
Attention: Transit Director
530 Industrial Blvd., McDonough, GA 30253
H
C
H
OW
OMPLAINTS WILL BE
ANDLED
Complaint forms must be signed and dated to be considered complete. Completed forms must be submitted
no more than 180 days from the date of the alleged incident. All forms must be submitted to the Henry County
Transit Department (HCTD). The HCTD will process only completed complaints.
Once a completed complaint is received, the HCTD will review and typically complete an investigation within 90 days from receipt of
the complaint. If more information is needed to resolve the case, a representative from the HCTD may contact the complainant.
Unless a longer period is specified by the HCTD, the complainant will have 10 days from the date of the request to send the
requested information. If the requested information is not received, the HCTD may administratively close the case. A case may be
administratively closed if the complainant no longer wishes to pursue it. After an investigation is complete, the HCTD will notify the
complainant, in writing, summarizing the results of the investigation, stating the findings and advising of any corrective action taken
as a result of the investigation.
O
O
F
C
THER
PTIONS FOR
ILING A
OMPLAINT
The Henry County Transit Department encourages persons to file complaints directly to the department. However, complaints may
be file with the Georgia Department of Transportation or the Federal Transit Administration.
Georgia Department of Transportation
Federal Transit Administration Office of Civil Rights
600 West Peachtree NW, Atlanta, GA 30308
1200 New Jersey Avenue SE, Washington, DC 20590
ADA C
F
OMPLAINT
ORM
Date Submitted
1.
Complainant Name
Complete Address
Street #, Street, City, State, Zip
Telephone Number(s)
Email Address
YES – If Yes,
NO – If No, go
2.
Are you filing this complaint on your own behalf?
go to #6
to #3
3.
Person Filing Complaint - NAME
Complete Address
Street #, Street, City, State, Zip
Telephone Number(s)
Email Address
4.
Relationship to person for whom filing the complaint
YES, I have permission to file this
NO, I do not have permission to file this
5.
Check One
complaint from the person listed above.
complaint from the person listed above.
P
1
2
AGE
OF
H
C
ENRY
OUNTY
A
D
A
(ADA)
MERICANS WITH
ISABILITIES
CT
C
P
F
OMPLAINT
ROCEDURES
ORM
T
P
C
YPE OR
RINT
LEARLY
Complaints about the accessibility of the Henry County Transit system or service, or complaints regarding believes of discrimination
because of a disability, may filed with the Henry County Transit Department. Complainants must provide all facts and circumstances
surrounding the issue or complaint so the incident can be fully investigated. For assistance with this form, or if information is needed
in another language, call 770-288-7433.
C
F
M
S
O
F
:
OMPLETED
ORMS
UST BE
UBMITTED TO
NE OF THE
OLLOWING
Henry County Transit Department
Email
tsalters@co.henry.ga.us
Mail / In Person
Attention: Transit Director
530 Industrial Blvd., McDonough, GA 30253
H
C
H
OW
OMPLAINTS WILL BE
ANDLED
Complaint forms must be signed and dated to be considered complete. Completed forms must be submitted
no more than 180 days from the date of the alleged incident. All forms must be submitted to the Henry County
Transit Department (HCTD). The HCTD will process only completed complaints.
Once a completed complaint is received, the HCTD will review and typically complete an investigation within 90 days from receipt of
the complaint. If more information is needed to resolve the case, a representative from the HCTD may contact the complainant.
Unless a longer period is specified by the HCTD, the complainant will have 10 days from the date of the request to send the
requested information. If the requested information is not received, the HCTD may administratively close the case. A case may be
administratively closed if the complainant no longer wishes to pursue it. After an investigation is complete, the HCTD will notify the
complainant, in writing, summarizing the results of the investigation, stating the findings and advising of any corrective action taken
as a result of the investigation.
O
O
F
C
THER
PTIONS FOR
ILING A
OMPLAINT
The Henry County Transit Department encourages persons to file complaints directly to the department. However, complaints may
be file with the Georgia Department of Transportation or the Federal Transit Administration.
Georgia Department of Transportation
Federal Transit Administration Office of Civil Rights
600 West Peachtree NW, Atlanta, GA 30308
1200 New Jersey Avenue SE, Washington, DC 20590
ADA C
F
OMPLAINT
ORM
Date Submitted
1.
Complainant Name
Complete Address
Street #, Street, City, State, Zip
Telephone Number(s)
Email Address
YES – If Yes,
NO – If No, go
2.
Are you filing this complaint on your own behalf?
go to #6
to #3
3.
Person Filing Complaint - NAME
Complete Address
Street #, Street, City, State, Zip
Telephone Number(s)
Email Address
4.
Relationship to person for whom filing the complaint
YES, I have permission to file this
NO, I do not have permission to file this
5.
Check One
complaint from the person listed above.
complaint from the person listed above.
P
1
2
AGE
OF
H
C
ENRY
OUNTY
ADA C
P
F
OMPLAINT
ROCEDURES
ORM
T
P
C
YPE OR
RINT
LEARLY
ADA Complaint Form – Continued
The complainant believes the discrimination experienced was based on – Check all that apply
6.
Accessibility
Disability
Other - List
Issues
7.
Date of alleged discrimination (MM, DD, YYYY)
8.
Location alleged discrimination took place
Explain, as clearly as possible, what happened and why complainant feels he/she was discriminated against.
9.
Describe all persons involved. Include name(s) and contact information of the person(s) who discriminated against the
complainant, if known. Use additional sheets if necessary.
10.
List any/all witnesses’ names and contact information. Use additional sheets if necessary.
11.
Has the complainant filed a complaint with any other federal, state or local agency, or with any federal or state court?
NO
YES – If Yes, check all that apply
Federal Agency or Court –
Date
Name / Location
State Agency or Court –
Date
Name / Location
Local Agency or Court –
Date
Specific County / Court / Agency
S
D
R
IGNATURE AND
ATE
EQUIRED
Complainant’s Signature
Date
If Sections 3, 4 and 5 Completed, Person’s Signature Required
Signature
Date
H
C
U
O
ENRY
OUNTY
SE
NLY
Date Received by HCTD
Date Copied to Risk
HCTD Staff Investigating Complaint
HCTD Findings / Notes
P
2
2
AGE
OF
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