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. This information is available in alternative formats upon request to the ADA Coordinator.

For questions, please contact:

City of Elk Grove
ADA Coordinator
8380 Laguna Palms Way, Suite 200, Elk Grove, CA, 95758
kreddig@elkgrovecity.org
Voice: 916-478-2249
Fax: 916-691-2001
TTY/TDD: (888) 435-6092

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

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Disability Advisory Committee

Access Request and Complaint Form for Persons with Disabilities