HomeMy WebLinkAboutCity of Iowa City Grievance FormCity of Iowa City
Complaint Form
Americans with Disabilities Act (ADA)
*Printable Form Only*
Section 1:
Please fill in completely and legibly. If the information is incomplete or it cannot be read, the
complaint will not be investigated.
Last Name Middle Initial First Name
Street Address City State Zip Code
Telephone Number (including area code) Best time to call this number
Alternative Telephone Number (including area code Best time to call this number
Email Address
Section 2:
Please provide a complete description of the specific issue(s) you believe are inconsistent with
Title II of the Americans with Disabilities Act (use additional pages as necessary and provide
documentation supporting the allegation).
Section 3:
Please provide the specific location(s) of the ADA issues prompting this complaint.
Section 4:
Please provide the date when the ADA non-compliance occurred/was noted.
Section 5:
Please state as specifically as possible what you think should be done to resolve the complaint.
Please sign and date this form
Signature Date
Mail Completed Complaint for to:
Simon Andrew: ADA Coordinator/Assistant to the City Manager
City Manager’s Office
410 E Washington St.
Iowa City, Iowa 52240
For Office Use Only:
Date received Date investigated
Results (with supporting documentation or photographs):
Date Complainant contacted Method of Contact: Phone
Letter
Email
Complaint Resolved? Yes
No