Sidewalk Accessibility Grievance Form | Department on Disability

Name of Person filing grievance or complaint *

Address *

City *

State *

Zip Code *

Telephone Number

Telephone Number or Email Address is required.

E-Mail Address

E-Mail Address or Telephone Number is required.

Person alleging grievance or complaint

I certify that I have the authorization from the person with a Mobility Disability to make this request on their behalf. *

Yes.

Address of Person alleging grievance or complaint

City

State

Zip Code

Telephone Number of Person alleging grievance or complaint

COMPLAINT

City Department, Service, Program

Address or Location where grievance or complaint occurred

City

State

Zip Code

Telephone Number

Date of alleged grievance or complaint *

Month

Day

Year

Describe the alleged grievance or complaint. *

Has this complaint been filed with the Department of Justice or any other Federal, State, or local civil rights agency or court? *

Name of Agency or Court

Name of Contact Person

Address

City

State

Zip Code

Telephone Number

Date Filed with Department of Justice or any other Federal, State, or local civil rights agency or court

Month

Day

Year

Additional space for description of alleged grievance or complaint

Information provided in a grievance or complaint may be subject to public disclosure as part of the Willits v. City of Los Angeles Settlement Agreement.

Signature *

Please sign the Sidewalk Accessibility Grievance Form with your name. By signing this document, you are verifying that the content you are submitting is correct.

Signature Date

Instructions: If you do not wish to submit your grievance online, please fill out this form in black ink or type, sign and return (mail, fax or e-mail) to the address as listed.

Mail, fax or e-mail the completed form to the following address:
Department on Disability, Disability Access and Services ADA Compliance Officer
201 North Figueroa Street, Suite 100 Los Angeles, CA 90012
Fax: (213) 202-2715
dod.srpar@lacity.org

Please note, this form is for Sidewalk Accessibility Grievances only and not to submit an Access Request repair. If you are a Member of the Settlement Class who wishes to submit a repair request please do so by visiting MyLA311 Access Request.