Cambria County Transit Authority Ada Complaint Form Template printable pdf download

Cambria County Transit Authority Ada Complaint Form Template

Cambria County Transit Authority

ADA Complaint Form

CamTran prohibits discrimination in all of its programs and services on the basis of a disability.

If you feel you have been discriminated against because of a disability, please provide the

following information in order to assist us in processing your complaint.

Please submit your complaint to:

ADA Administrator

Cambria County Transit Authority

502 Maple Avenue

Johnstown, PA 15901

Please print clearly.

Section I:

Name: ________________________________________________________________________

Address: ______________________________________________________________________

City: ______________________________________ State: _________ Zip Code: ____________

Telephone (Home): ________________________ Telephone (Cell): _______________________

Accessible Format Requirements: [ ] Large Print [ ] TDD [ ] Audio Tape [ ] Other: _________

Section II:

Are you filing this complaint on your own behalf?

[ ] Yes*

[ ] No

*If you answered “yes” to this question, go to Section III.

Please supply the name and relationship of the person you are completing the complaint form

for:

Name: ____________________________________ Relationship: ________________________

Please explain why you have filed for a third party: ____________________________________

Please confirm that you have obtained the permission of the aggrieved party if you are filing on

behalf of a third party. [ ] Yes [ ] No

Section III:

Date of Incident (MM/DD/YYYY): _____________________

Time of Incident: _____________

Location of Incident: ____________________________________________________________

Transit Service (Fixed route/Reserve-a-Ride/Paratransit/Inclined Plane/Other): _____________

Route Name/Number: _____________________

Vehicle Number: ____________________

Direction of Travel: [ ] Inbound

[ ] Outbound

Mobility Aid Used (if any): ________________________________________________________

Cambria County Transit Authority Ada Complaint Form Template