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Complaint Concerning Accessibility of

U.S. Department of Transportation

Airline Service

Aviation Consumer Protection Division , C-75-D

1200 New Jersey Ave., SE

(Passengers with Disabilities)

Washington, DC 20590

For reporting incidents believed to constitute discrimination against a passenger with a disability or a violation of

DOT’s accessibility rules under the Air Carrier Access Act (14 CFR Part 382). Please complete this form and mail it to

the above address. Please type, write legibly, or print, in black ink. You may wish to keep a photocopy of this form. If

available, enclose a copy of your airline ticket or travel agency itinerary sheet.

Passenger Information

Name: _____________________________________________________________________________

Street Address: ______________________________________________________________________

City: ________________________________________ State: ________ Zip: ____________________

Telephone:

Home: ________________________________ Business: ________________________________

(with area code)

E-mail address (if any): ____________________________________________

Person to contact

about this complaint, if other than the passenger:

Name: _____________________________________________________________________________

Street Address: ______________________________________________________________________

City: ________________________________________ State: ________ Zip: ____________________

Telephone:

Home: ________________________________ Business: ________________________________

(with area code)

E-mail address (if any): ____________________________________________

Flight Information

List only the flight(s) on which the discrimination or accessibility problems occurred.

Date

Airline

Flight number

From (city)

To (city)

: The authority for collecting this information is contained in 49 U.S.C. 46101. We need this information in order to

RIVACY

TATEMENT

investigate your complaint. The personal information will be used primarily for enforcement and compliance purposes. The Department will not

disclose the name or other identifying information about an individual unless it is necessary for enforcement activities against an entity alleged to

have violated Federal law, or unless such information is required to be disclosed under the Freedom of Information Act, 5 U.S.C. 552, or as is

allowed through the publication of a routine use in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. To further the Department's

enforcement activities, information we have about you may be given to appropriate Federal, State, or local agencies. Additional disclosures of

information may be made to members of Congress or its staff; to volunteer student workers within the Department of Transportation so that they

may perform their duties; to the news media when release is made consistent with the Freedom of Information Act and 49 CFR Part 7; and to the

National Archives and Records Administration and General Services Administration to perform records management inspection functions in

accordance with their statutory responsibilities. Furnishing of the requested information is voluntary, except that the failure to provide such

information may result in our being unable to process your complaint.

Issued 4/99

DOT Use

Case number:

Date logged:

Complaint code:

Form 382 - Complaint Concerning Accessibility Of Airline Service (Passengers With Disabilities) - Department Of Transportation Forms

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