City of Winston-Salem | ADA Grievance Form

Title II of the Americans with Disabilities Act
Section 504 of the Rehabilitation Act of 1973
Grievance Form

A (*) denotes a required field.

*Grievant Name

*Address

*City, State and Zip Code

*Home Telephone

Business/Cell Phone

*Email Address

The following section is to be completed only if the aggrieved person is not the individual completing this form. Skip to next section if this does not apply to you.

Reporting Individual Name

Person(s) Affected by the Situation (if other than reporting individual):

Reporting Individual Address

City, State and Zip Code

Reporting Individual Preferred Telephone

*Program or Facility Alleged to Be Inaccessible

*When did the situation occur? Enter date.

*Describe the situation or way in which the program is not accessible, providing the name(s) where possible of the individuals who were involved in the situation.

*Have efforts been made to resolve this complaint through the Request for Accommodation with the ADA Coordinator?
Yes
No

If "Yes" to previous question, what were the results?

*Today's Date

Upon request, reasonable accommodation will be provided in completing this form or copies of the form will be provided in alternative formats. Please contact the ADA Compliance Coordinator.

Title II of the Americans with Disabilities Act Section 504 of the Rehabilitation Act of 1973 Grievance Form

City Attorney

Title II of the Americans with Disabilities Act
Section 504 of the Rehabilitation Act of 1973
Grievance Form