ADA Grievance Form

Please complete the form and submit it within 180 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 ADA Coordinator, Jason Crampton at 480-782-3402 or 7-1-1 via AZ Relay Service.

Type of Grievance (Check All That Apply)
Contact Information

Reporting Individual
Name
Address
Authorized Representative of Reporting Individual (if any)
Name
Address
Details of Complaint/Incident

Use your mouse (desktops and laptops) or finger (mobile devices) to draw your signature above.