ADA Grievance Form

Grievance Form

1. Instructions This section is complete This section is incomplete
2. Grievant's Contact Information This section is complete This section is incomplete
3. Description of Grievance This section is complete This section is incomplete

If you have been discriminated against on the basis of disability in any of the City of Chino's services, programs or activities, and you would like to file a grievance, please complete all sections of this form.
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Today's Date*
Today's Date
First Name*
Last Name*
Address
City
State
Zip Code
Phone Number*
Email Address*
Legally Authorized Representative
If a legally authorized representative is filing the grievance on your behalf, their name, address and phone must also be included.
Do you have a legally authorized representative filing the grievance on your behalf?
Representative's First Name
Representative's Last Name
Representative's Address
Representative's City
Representative's State
Representative's Zip Code
Representative's Phone Number
Representative's Email
Other Person or Group
If your grievance is being filed on behalf of another person or group, all of the grievants should be identified by name, if possible.
Is your grievance being filed on behalf of another person or group?
Person or Group Name
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