City Of Lenexa Ada Complaint Form For Denial Of Reasonable Accommodation
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1CITY OF LENEXA
ADA COMPLAINT FORM
FOR DENIAL OF REASONABLE ACCOMMODATION
This form is provided in accordance with the Americans with Disabilities Act (ADA) and City of Lenexa
Administrative Policy AD08-E and is to be completed by or on behalf of a person who has been DENIED
by the City ADA Coordinator a reasonable accommodation due to a qualifying disability.
Complete this form in its entirety, as it constitutes your formal complaint against the City of Lenexa.
TO: CITY OF LENEXA, KANSAS
YOU ARE HEREBY NOTIFIED of the following complaint made by the undersigned as a result of a denial of or
dissatisfaction with a reasonable accommodation.
COMPLAINANT NAME: _____________________________________________________________________
Address: ________________________________________________________________________________
Phone: _______________________________ Email: ____________________________________________
Name & Contact information of person completing the form (if different): _______________________________
_________________________________________________________________________________________
Please describe the denial by the City of a reasonable accommodation, or your disatisfaction with the offered
accommodation(s), including but not limited to location, date of denial or dissatisfaction, persons involved, etc.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
If accommodations were offered by the City, please describe why they would not be feasible in your case:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
(attach additional pages or documentation, if necessary)
Date: ____________________ Signature: _____________________________________________________
Complainant or Authorized Representative
ADA Coordinator/Assistant to the City Administrator
Return completed form to:
th
12350 W. 87
Street Parkway
Lenexa, KS 66215
Phone: (913) 477-7550
Fax: (913) 477-7639
Email:
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