CITY OF RIO RANCHO AMERICANS WITH DISABILITIES ACT (ADA) – GRIEVANCE FORM/COMPLAINT OF ACCESS VIOLATION OR DISCRIMINATION ON THE BASIS OF DISABILITY

Person identifying access violation or discrimination

Name:

Address:

Telephone Number:

Email:

Authorized representative of individual (if any)

Name:

Address:

Telephone Number:

Email:

Please describe the alleged violation of access requirements, or discriminatory action, in enough detail so that the nature of your grievance can be clearly understood

Please give the date(s), time(s) and location(s) of the incident(s) or observation(s) you are reporting

If the incident involves City employee(s) please provide his or her name(s), if known

Please give the name(s) and address(s), if known, of any witnesses to the access violation or alleged discrimination

What actions do you request the City take to correct the alleged ADA non-compliance violation or discrimination

The City will make reasonable effort to ensure that confidentiality is maintained throughout the complaint and investigation process, to the extent consistent with the law, adequate investigation, and appropriate corrective action.

If you need assistance filling out this form or have questions, please call (505) 891-5015.