ADA Complaint Form

In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990 and Section 504 of the Rehabilitation Act of 1973, the City of Fort Collins (“City”) will not discriminate against qualified individuals with disabilities on the basis of disability in its provision of public facilities, services, programs or activities.

If you feel you have been discriminated against on the basis of a disability through the City of Fort Collins’ provision of a public facility, service, program or activity (pursuant to the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973), please complete this ADA Complaint Form.

Please complete all questions to the best of your knowledge. If you need assistance in completing this form, including sign language assistance, documents in Braille or other ways of making information and communications accessible, please contact the City’s ADA Coordinator via email, at adacoordinator@fcgov.com, or by calling 970.416.4254.

PLEASE RESPOND TO ALL QUESTIONS TO THE BEST OF YOUR KNOWLEDGE:

1. Complainant

Your Name:

Address:

City:

State:

Zip code:

Telephone contact #:

Email:

2. Person discriminated against (if someone other than you, complainant)

Name:

Address:

City:

State:

Zip code:

Telephone contact #:

Email:

3. Which City of Fort Collins' public facility, program, service or activity is the complaint about: (complete all that apply to this complaint, otherwise leave blank)

City Facility Name:

City Program, Service or Activity:

City Employee(s) Involved:

4. Date of incident (resulting in complaint): This question requires a valid date format of MM/DD/YYYY.

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5. Location of incident (resulting in complaint):

6. In your own words, describe the circumstances surrounding this complaint. Please provide as many details as possible, such as time of day, specific actions, events, interactions, names and job titles, who said what, who was present at the time, etc.

Circumstances surrounding this complaint:

7. Were there any witnesses to the incident?

Please provide as much information as possible about any witnesses.

Witness A:

Witness Name:

Address:

City:

State:

Zip code:

Telephone contact #:

Email:

Any other identifying details:

Please provide as much information as possible about any witnesses.

Witness B:

Witness Name:

Address:

City:

State:

Zip code:

Telephone contact #:

Email:

Any other identifying details:

8. Have any efforts been made to file or resolve this complaint through the internal grievance procedures of any City of Fort Collins department?

Which department?

What is the status of the grievance?

9. Have you filed a complaint about this same incident with any other agency or court?

If so, fill in the organization’s name and contact person:

Space Cell	Organization Name	Contact Person
Federal Agency:	Federal Agency:: Organization Name	Federal Agency:: Contact Person
Federal Court:	Federal Court:: Organization Name	Federal Court:: Contact Person
State Agency:	State Agency:: Organization Name	State Agency:: Contact Person
State Court:	State Court:: Organization Name	State Court:: Contact Person
City or Local Agency:	City or Local Agency:: Organization Name	City or Local Agency:: Contact Person
City or Municipal Court:	City or Municipal Court:: Organization Name	City or Municipal Court:: Contact Person

Other - Please provide the full contact information for the person with the “other” agency or court:

Name:
Affiliation:
Address:
City:
State:
Zip code:
Telephone number:
Date filed:

10. Type your name in the space below to provide an electronic signature.

11. Today's date: This question requires a valid date format of MM/DD/YYYY.

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12. In order to receive a copy of this complaint, please enter your email below: This question requires a valid email address.

The City’s ADA Coordinator will notify you when your complaint has been received. If you do not receive confirmation within 2 weeks, please call or email the City’s ADA Coordinator at 970.416.4254 or adacoordinator@fcgov.com.