Tri River Transit Authority Ada Complaint Form (Page 2 of 3) in pdf

Tri River Transit Authority Ada Complaint Form Page 2

6. I believe that the discrimination I experienced was based on (check all that apply)

☐ Accessibility issue

Discrimination based on disability

Other

☐

7. Date of alleged discrimination (Month, Day, Year):

8. Where did the alleged discrimination take place?

9. Explain as clearly as possible what happened and why you believe that you were

discriminated against. Describe all of the persons that were involved. Include the name

and contact information of the person(s) who discriminated against you (if known). Use the

back of this form or separate pages if additional space is required.

10. Please list any and all witnesses’ names and phone numbers/contact information.

Use the back of this form or separate pages if additional space is required.

11. What type of corrective action would you like to see taken?

12. Have you filed a complaint with any other federal, state, or local agency, or with any

federal or state court?

Yes If yes, check all that apply.

☐

Federal Agency (List agency’s name)

☐

Federal Court (Please provide location)

☐

State Court

☐

State Agency (Specify agency)

☐

County Court (Specify court and county)

☐

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Tri River Transit Authority Ada Complaint Form Page 2