Americans With Disabilities Act (Ada) Complaint Form Related To City Programs, Facilities And Activities
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1AMERICANS WITH DISABILITIES ACT (ADA) COMPLAINT FORM
RELATED TO CITY PROGRAMS, FACILITIES AND ACTIVITIES
Date Filed: ________________
Complainant Information:
Complainant’s Representative
Information: (If appropriate)
Name: _____________________________
Name: _____________________________
Address: ___________________________
Address: ___________________________
City: ______________________________
City: ______________________________
Zip Code: __________________________
Zip Code: __________________________
Phone: ____________________________
Phone: ____________________________
Email: _____________________________
Email: ______________________________
Details of Complaint
Date of incident:
(Must be filed within 60 days of incident) _______________________________________
Location of incident: ________________________________________________________
City department/staff you spoke with: ___________________________________________
Complaint Description:
(Please provide a brief summary of the situation regarding this ADA complaint. Include
the names of individuals involved and as much detail as possible).
Alternative means of filing complaints, such as personal interviews or a tape recording of the
complaint, will be made available to persons with disabilities upon request.
Send your completed form to:
Peter Fischer, ADA Coordinator
City of Phoenix Equal Opportunity Department
th
251 W. Washington Street, 7
Floor
Phoenix, Arizona 85003
peter.fischer@phoenix.gov
602-534-9276/Voice
602-534-1124/Fax
602-534-1557/TTY
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