Action Center / ADA Grievance Form / Monroe County, IN

ADA Grievance Form

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COMPLETE THIS FORM TO SUBMIT AN ADA GRIEVANCE.

The Americans with Disabilities Act (ADA) requires that the Monroe County Government (MCG) make its facilities, programs, and services accessible to persons with disabilities in accordance with the standards of the ADA. If an individual feels that he or she has been unable to access a MCG facility, program or service because of a lack of accessibility or has been discriminated against because of a disability, the individual should complete the ADA Grievance Form.

If this Submission is something other than an ADA grievance specific to County Buildings and Monroe County Government Programs this submission will be closed with no further action.

Procedure and instructions on how to file an ADA Grievance.

* Denotes a required field

ADA Grievance Form - Monroe County, Indiana

Please Do Not Complete The Following Field

Complainant*

Date of Incident*

MonthDay Year,

Person Preparing Form (if different from Complainant)

Relationship to Complainant

Street Address & Apt. No.

City

State

Zip

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

Phone

Phone Area Code-Phone 3-Phone 4 ext Extension

E-mail

Location of Incident*

Please provide a complete description of the specific grievance:*

Please state what you think should be done to resolve the grievance:*

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ADA Grievance Form

ADA Grievance Form - Monroe County, Indiana

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