ADA Title II Grievance Form

Instructions: Please fill out as much of this form as you can in black ink or type. If you need assistance, tell us and we would be happy to provide assistance with filling out this form. Sign and return (mail, fax or e-mail) to the following information listed below.

Department on Disability
Disability Access and Services ADA Compliance Officer
201 North Figueroa Street, Suite 100
Los Angeles, CA 90012
Phone: (213) 202-2766
Fax: (213) 202-2715
E-mail: DOD-ADA@lacity.org

COMPLAINT

If yes, please complete the following information below.

Strict confidentiality of all complaint information will be maintained. Sharing of information will be done only as needed to resolve the complaint.