2. Grievance Under Title II of the Americans with Disabilities Act
   Please fill out this form completely and as detailed as you are able.
4. First Name*
5. Last Name*
7. Street Address*
9. City*
10. State*
11. Zip Code*
13. Daytime Phone*
14. Evening Phone
15. Fax Number
17. Email Address*
21. Date of Occurrence*
    On or about what date did the subject of the grievance occur?
23. Location*
    Where did the act or event causing this grievance occur?
25. Statement of Grievance*
    Describe the act(s) and attach any supporting documentation pertinent to this claim.
27. Name(s) of the City Department(s), organization, or institution of this grievance claim*
29. State the nature of your disability and the reasonable accommodation you believe should be provided to you to resolve this grievance*
33. Has the complaint been filed with the City of Edmond ADA Coordinator or the Federal Department of Justice, or any other State of Federal agency or court?*

    1. Yes
    2. No
35. If yes, what is the status of the grievance?
37. If yes, list the name of the Agency or Court
38. Date Filed
40. Address
41. City
43. State
44. Zip Code
45. Telephone Number
49. Do you intend to file with another agency or court?

    1. Yes
    2. No
51. If yes, list the name of the Agency or Court
52. Telephone Number
54. Address
56. City
57. State
58. Zip Code
62. Acknowledgement

    1. I hereby certify that the above is a true and correct statement of my grievance under Title II of the Americans with Disabilities Act
64. If a person other than the listed grievant completed this form, please provide the name, address, phone number and relationshop of the person completing this form.
66. Please attach any supporting documents if applicable
68. Please allow 15 days for a response to this grievance.
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70. Submit Submit and Print

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