ADA Grievance Form
The City of Georgetown has established a grievance procedure for prompt and equitable resolution of complaints alleging discrimination on the basis of disability in the provision of City services, activities, or programs in violation of Title II.
s soon as possible but no lat
r the incident or condition observed as
Within 15 calendar days after receipt of a complaint, the ADA Coordinator will acknowledge receipt of the complaint and may, at his/her discretion, meet with the complainant to discuss the complaint.
Within 30 calendar days after receipt of a complaint, the ADA Coordinator will respond to the complaint in writing or, if requested, in an alternative format such as large print or audio tape, to accommodate a disability.
Name of Complainant
Name of Agent/Representative
Address of Complainant
Address Line 2
State / Province / Region
Postal / Zip Code
Telephone of Complainant
Email of Complainant
Preferred Method of Contact
What type of activity is this grievance?
Date Incident Occurred
Which City of Georgetown Department, if any, is alleged by you to have failed compliance with the ADA law?
Names of Those Involved
Please identify the names of all City of Georgetown agents, representatives or employees, if any, whom you contend were involved.
Description of Incident
Give a brief description of incident that made the basis of your grievance. Include in your response the identity of the service, activity, program or benefit you contend your access has been denied or any other manner you content you have been subjected to discrimination. Please also provide in your description specific dates, times and places as well as the names, addresses and telephone numbers of any and all persons who may have witnessed or been involved in the act or basis of your complaint.
Please provide a suggested outcome for resolution
File upload limit:
• Any other written information or documentation (such as photos, maps, diagrams) to completely explain the incident or condition and the alleged violation.
Please install Adobe® Flash® Player system plug-in to draw your signature