ADA Grievance Form

ADA GRIEVANCE FORM

Any person alleging an action prohibited by federal regulations contained in Title II of the Americans with Disabilities Act of 1990 (ADA) or Section 504 of the Rehabilitation Act of 1973 may file a written complaint with the Town of Burgaw ADA Program within 60 days after the alleged action occurred.

Last Name

First Name

MaleFemale

Address

Mailing Address

Street Address Line 2

CityState

Zip

Email

example@example.com

Home Phone

Work Number

Please enter a valid phone number.

Date and place of alleged action(s). Please include earliest action date and most recent action date

Name of individuals responsible for the action(s): (if you do not know the names(s) or there was not specific person involved you may leave this blank)

Describe the alleged prohibited action. Explain as clearly as possible what happened and why you believe this is a prohibited action (attach additional page(s), if necessary)

Describe the alleged prohibited action. Explain as clearly as possible what happened and why you believe this is a prohibited action.

Retaliation against a complainant or individual assisting a complainant under this grievance procedure is prohibited. If you feel you have been retaliated against, please explain the circumstances below. Explain what action you took which you believe was the cause for the alleged retaliation:

Names of persons (witnesses or others) whom we may contact for additional information to support or clarify your complaint: (Name, Address, and Phone Number)

Have you discussed the complaint with any Town of Burgaw representatives? If yes, please provide the name, position, and date of discussion

Please provide any additional information that you believe would assist with an investigation

Briefly explain what remedy you are seeking for the alleged action

WE CAN NOT ACCEPT AND UNSIGED COMPLAINT, PLEASE SIGN AND DATE THE COMPLAINT FORM BELOW,

COMPLAINTANT'S SIGNATURE

DATE

Date

Town of Burgaw ADA Coordinator

Kimberly Rivenbark

109 N Walker St

Burgaw, NC 28425

krivenbark@burgawnc.gov