Formal ADA Grievance Submission Form

Personal Information

Title

First

Middle

Last

Suffix

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Phone

Ext:

Disability/disabilities of individual(s) affected

Please do not contact me personally.

Reporting Agent

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

First

Last

Relationship to Complainant (if different from Complainant):

Information on 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)

Type of Issue/Relates to OAG

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

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)

Additional Information (file)

One file only.
8 MB limit.
Allowed types: gif, jpg, png, txt, rtf, html, odf, pdf, doc, docx, xls, xlsx, xml, .

Are the circumstances continuing?

Yes

Unknown

Please state your suggested outcome for resolution

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

Yes

Please identify the agency or court that you have notified.

For More Information

Alternative means of filing grievances will be made available if necessary. For more information, contact:

ADA Coordinator
300 West 15th Street, 2nd Floor 
Austin, Texas 78711 
512-463-2009 (voice) 
Individuals with hearing loss may call Relay Texas toll free 7-1-1 or 1-800-RELAY-TX  (1-800-735-2989).

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