Americans with Disabilities Act Discrimination Complaint Form

2. Person Filling out this form

4. Name*

6. Address*

8. City*

9. State*

10. Zip Code*

12. Phone Number*

13. Email Address*

15. Person (s) Discriminated Against (if other than the complainant)

    Please enter name, address and phone number

17. Discriminatory Incident

19. Government, organization, institution or business which you belived discriminated

21. Name*

23. Address

25. City

26. State

27. ZIP

29. Telephone number

31. When did this discrimination occur? Date*

33. Primiary type of disability*
    -- Select One --mobilitycognitive/intellectual/developmentallearningmental/physchiatricvisionhearingseizurespeechHIV/AIDSdiabetesother or not listed

35. Issue
    -- Select One --employmentinterpreter/assistive listeningservice animalhousingretaliationdenial of services/refusal to admitother or don't know

37. Describe the acts of discrimination*

39. Has the complaint been filed with another bureau of the Department of Justince or any other Federal, State, or local civil righst agency or court?*

    1. Yes
    2. No

41. Agency or Court*

Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field