ADA Grievance/Complaint Form

ADA Grievance Complaint Form

The information collected in this form will be used to file a formal Grievance/ Complaint. During the investigation of the complaint, you may be contacted to further discuss the complaint and/or solutions. If you do not wish to participate in a formal grievance procedure, please mark the box at the bottom of this form.
Name*

First Name Last Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Which one(s) do you prefer to be contacted by?

PhoneEmailPostal MailOther
Classification of Accessibility Concern/Inquiry (Select All That Apply)
Please Indicate the Nature of Your Complaint
Information About Complaint
Specific Address or Location in the City of Peoria * if known

If Known*

State / Province
Please explain what happened in detail.*
Please describe your suggested resolution.
Please provide any related files (Photos, documents, voice records, etc.)

Cancelof
Do you wish to proceed with a formal grievance/complaint?

YesNot at this time
Signature (not required)

Clear
Date

MonthDayYear
Your grievance/complaint will be submitted to the ADA Coordinator who may contact you for additional information. You will receive a written response to your complaint within 30 days. If another form of response is required, or you have questions regarding your complaint, please contact City of Peoria ADA Coordinator: Melodi Green, Peoria City Hall, 419 Fulton St. Room 303. Peoria, Il 61602, Phone: 309.494.8842, Email: eoo@peoriagov.org
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ADA Grievance Complaint Form

Classification of Accessibility Concern/Inquiry (Select All That Apply)

Information About Complaint