ADA Grievance Submission – Angelina County

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Email *

Disability/disabilities of individual(s) affected

Do not contact

Please do not contact me personally.

Disability/disabilities from State,

Reporting Agent

First

Last

Name of Agent/Representative/Person preparing complaint (if different from Complainant):

Relationship to Complainant (if different from Complainant):

Information on Incident

Location of Incident *

Location of issue giving rise to grievance (please provide an address if possible)

Time/Date of issue giving rise to the grievance (if applicable)

Date

Time

Give a brief description of the incident that made the basis of your grieveance. *

Include in your response the identity of the service, activity, program, or benefit at issue. Please also provide in your description specific dates, times, and places, as well as the names, addresses, and telephone numbers of any and all persons who may have witnessed or been involved in the act or basis of your complaint. (Attach additional information, if needed)

File Upload

Click or drag a file to this area to upload.

One file only. 8 MB limit. Allowed types: gif, jpg, png, txt, pdf, doc, docx, xls,.

Are the circumstances continuing?

Yes
No
Unknown

Please state your suggested outcome for resolution *

Have you filed a complaint with any other Federal, State, or local agency or court?

Yes
No

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ADA Grievance Submission Form

Information on Incident