ADA_Complaint

ADA Complaint / Assistance Form

Please fill out as much of this form as you can. If you need help, tell us, and we would be happy to provide it. If you don't know the answer to something, please leave it blank.

(*) Required Fields

Your Name*:

Your Address*:

Your City*:

State*:

Zip Code:

Your Phone (Day)*:

Check if this is a TTY?

Your Email:

Your Fax:

Are you a Veteran:

Yes

How do you prefer to be contacted (i.e. phone, email, etc.)?*

The Office of Disability Rights investigates and resolves disability access problems and issues. Access issues usually fall into one of several categories. Please let us know which category best describes your issue:

Access Issue Category*

Architectural Access − Please check here if the access problem is about a building −− for example, a wheelchair ramp is needed, accessible bathrooms are not available, or counters and phones are not at the correct height for wheelchair users.

Programmatic Access − Please check here if the access problem is about a service −− for example, you cannot get or maintain a city benefit or service because of a disability, or you asked for a reasonable modification of a policy, practice or procedure in order to obtain District of Columbia benefits or services, but were denied one.

Communication Access − Please check here if the access problem involves communication − for example, you need an interpreter, materials in alternative formats, or other auxiliary aids and services in order to have equal access to information and communications for a District of Columbia benefit, service or activity.

Employment – Please check here if the problem relates to your employment or application with the DC government – for example, you were denied a reasonable accommodation by your employer.

Which District agency does this complaint involve?

Please describe the problem you encountered:

Please give us the date of the most recent problem:

Please give us the location of the problem:

Is there a change in policy or procedure you wish to see that would be helpful in solving this problem?

Names and Positions of Staff Encountered (if known).

Name:

Position:

Was there anyone else who had the same difficulty, or with whom you would want us to talk in order to get more information?

Names of Other Persons to Contact

Name:

Phone:

Name:

Phone:

Please submit this form to:

Office of Disability Rights, 441 4th Street, NW, Suite 729N, Washington, DC 20001

Or fax to (202) 724−9484

Thank you for submitting this information. You will receive a response from the ODR within 5 business days. If you do not, please contact us via phone at (202) 724−5005, TTY (202) 727−3363, or via e−mail at odr.complaints@dc.gov.