ADA Compliance Grievance Complaint Form

2. 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.
4. Compainant Full Name*
6. Address Line 1*
8. Address Line 2
10. City*
11. State*
12. ZIP Code*
14. Best Contact Phone Number*
15. Best Contact Email Address*
17. I require Texas Relay Service 711 (TTY) *

    1. Yes

    1. No
19. Preferred Method(s) of Communication*

    Check all that apply

    1. Voice Telephone
    2. Texas Relay Service 711 (TTY)
    3. Email
    4. US Postal Mail
    5. Other
21. Other description
23. Describe Your Complaint of Discrimination Based Upon Disability*
    Be specific, and give date(s), time(s) and location(s).
25. Persons Named in Your Complaint*
    List the names of (or describe) all persons in your complaint. Indicate job title, department or division, when possible.
27. Evidence and Documentation*
    List the names of (or describe) all persons in your complaint. Indicate job title, department or division, when possible.
29. 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?
31. Certification

    1. By clicking this box, you certify your submission, that the information and statements provided above are true.
33. Date submitted*
    Date submitted
Leave This Blank:


35. 1. Receive an email copy of this form.
36. Email address

    This field is not part of the form submission.

37. Submit

* indicates a required field