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ADA Compliance Grievance Complaint Form
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This form has been modified since it was saved. Please review all fields before submitting.
The City of Irving will make every effort to ensure that confidentiality is maintained throughout the complaint process. This means the city will share any sensitive information provided below on a need-to-know basis.
Complainant Full Name
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Address Line 1
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Address Line 2
City
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State
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ZIP Code
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Best Contact Phone Number
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Best Contact Email Address
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I require Texas Relay Service 711 (TTY)
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Preferred Method(s) of Communication
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Voice Telephone
Texas Relay Service 711 (TTY)
Email
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Other description
Describe Your Complaint of Discrimination Based Upon Disability
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Be specific, and give date(s), time(s) and location(s).
Persons Named in Your Complaint
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List the names of (or describe) all persons in your complaint. Indicate job title, department or division, when possible.
Evidence and Documentation
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List the names of (or describe) all persons in your complaint. Indicate job title, department or division, when possible.
Have Efforts Been Made to Resolve this Complaint Through a Request for Accommodation with the ADA Coordinator's Office?
What remedies or solutions are seeking?
Certification
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Date submitted
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