ADA Grievance Form

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This Grievance Form is established to meet the requirements of the Americans with Disabilities Act of 1990 (ADA). It may be used by anyone who wishes to file a complaint alleging violation on the basis of disability in the provision of services, activities, programs or benefits by the City of Homer. The City’s Personnel Policy governs employment-related complaints of violation.

The complaint should contain information about the alleged violation such as name, address, phone number of complainant and location, date, and description of the problem. Alternative means of filing complaints, such as personal interviews or a tape recording of the complaint will be made available for persons with disabilities upon request. All written complaints received by the ADA Coordinator or designee, appeals to the City Manager or designee, and responses from these two offices will be retained by the City of Homer for at least three years.

If you need assistance, require an accessible format, or have questions about this form, please contact the City of Homer ADA Coordinator at: rkrause @ci.homer.ak.us or (907) 435-3109. The City of Homer's Grievance Procedures can be found by selecting this link.

Type of Grievance (check all that apply) *

Accommodation Request

City Program/Service

City Facility Accessibility

Other

Reporting Individual

Full Name *

Mailing Address *

City *

State *

Zip Code *

Phone *

Alternate Phone

Email *

I am reporting:

Authorized Representative of Reporting Individual (if applicable)

Full Name

Mailing Address

City

State

Zip Code

Phone

Alternate Phone

Details of Violation

Date of Incident *

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Per City of Homer Grievance Procedures, grievances should be submitted as soon as possible but no later than 60 calendar days after the alleged violation.

Time of Incident

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Time of Incident AM

Time of Incident PM

Please include an estimated time, if known.

Department/Facility/Location Involved *

Briefly describe the location, or name the department/facility involved

Describe the Violation *

Have attempts been made to resolve the violation through a City Department? *

If yes

I, the reporter/authorized representative for this grievance, warrant the truthfulness of the information provided in this application.

Electronic Signature *

Acknowledgement *

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree that I am the person identified above and that I acknowledge and agree to the above Terms of Acceptance.

ADA Grievance Form

Contact Information