ADA Request for Solution

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Please complete the form and submit it within 60 calendar days of the incident or decision to which this complaint relates to. If you need assistance, require an accessible format or have questions about this form, please contact the ADA Coordinator at 480-782-3402 or 7-1-1 via AZ Relay Service.

Type of Grievance (Check All That Apply)

Accommodation Request (modification and/or auxiliary aids and services)

Program/Service

Facility Accessibility

Other

Please List Type of Grievance

Contact Information

Reporting Individual

First Name

Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone

Alternate Phone

Authorized Representative of Reporting Individual (if any)

First Name

Last Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone

Alternate Phone

Details of Complaint/Incident

Date/Time of Incident

Department/Facility/Location Involved

Describe the incident/complaint with enough detail so the nature of the grievance can be understood.

Have attempts been made to resolve the complaint through a City Department? If yes, please describe the efforts that have been made.

Remedy Sought. What action do you want taken?

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ADA Request for Solution

Contact Information

Details of Complaint/Incident