ADA Request and Complaint Form/Grievance Process

Instructions

This form is to be used only for requests or concerns about access, for those with disabilities, 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" (Printable Form below)

ADA Access Request and Complaint Form for Persons with Disabilities

Your Name

Address

City

State

Telephone

E-mail

Today's Date

Today’s Date

Incident Information

Date of Accessibility Incident

Date of accessibility incident

Nature of request or complaint

Program/Service/Activity (if applicable)

Building/Facility (if applicable)

Address/Location

Would you like to be contacted regarding the resolution of this matter?

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 fifteen (15) 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.