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Disability Advisory Committee

Access Request and Complaint Form for Persons with Disabilities

 

Instructions:

(Printable Form below)

 

This form is to be used for requests or concerns about access to City of Elk Grove buildings, programs, services or activities. Concerns pertaining to buildings and programs not operated by the City of Elk Grove should be directed to the appropriate responsible party.

Complete the information below with or without the assistance of City staff. After completion of this form, click on "Submit Form".

Date of accessibility incident:
Nature of request or complaint:
Program/Service/Activity (if applicable):
Building/Facility (if applicable):
Address/Location:
Your Name:
Address:
City:
State:
Telephone:
E-mail:
Today’s Date:
Would you like to be contacted regarding the resolution of this matter?	Yes No
The City will make every effort to address your concern within a reasonable period of time. You will be contacted by the ADA Coordinator within five (5) business days. If your concern pertains to an agency other than the City of Elk Grove, we will forward this form to the responsible agency. All written complaints and responses will be retained by the City of Elk Grove for at least three years. If the response by the ADA Coordinator or designee does not satisfactorily resolve the concern, the complainant may appeal the decision within fifteen (15) business days after receipt of the response to the City Manager or designee.

For questions, please contact:

Jim Ramsey, Citywide ADA Coordinator
City of Elk Grove
8401 Laguna Palms Way
Elk Grove, CA, 95758

Voice: 916-478-2250
Fax: 916-627-4250
TTY/TDD: (888) 435-6092

E-mail: jramsey@elkgrovecity.org

 

Printable Form	PDF File
Access Request and Complaint Form for Persons with Disabilities	Fill-in pdf

 

Click here to download reader.