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Americans with Disabilities Act Discrimination Complaint Form

Please complete this form. Fields marked with an asterisk (*) are required.

Person filling out this form

Last Name *

First Name *

Middle

Suffix

Address *

City *

State *
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew
HampshireNew JerseyNew
MexicoNew YorkNorth
CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTenneseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaDistrict of
ColumbiaGuamNorthern
Mariana IslandsPuerto RicoVirgin Islands

ZIP *

Telephone * (preferred)

Email *

Person(s) Discriminated Against (if other than the
complainant)

Discriminatory incident

Government, organization, institution or business which you believe has
discriminated

Name *

Address *

City *

State *
HampshireNew JerseyNew
MexicoNew YorkNorth
ColumbiaGuamNorthern

ZIP *

Telephone Number

When did the discrimination occur?
Date

Primary type of disability *
mobilitycognitive/intellectual/developmentallearningmental/psychiatricvisionhearingseizurespeechHIV/AIDSdiabetesother or not
listed

Issue *
employmentphysical accessinterpreter/assistive
listeningservice animalhousingretaliationdenial of services/refusal to admitother
or don't know

Describe the acts of discrimination *

4000 characters remaining.

Have efforts been made to resolve this complaint
through the internal grievance procedure of the government, organization,
institution or business? *
YesNo

Has the complaint been filed with another bureau of
the Department of Justice or any other Federal, State, or local civil rights
agency or court? *
YesNo

Agency or Court

Paperwork Reduction Act Statement: A federal agency may not conduct or
sponsor, and a person is not required to respond to a collection of information
unless it displays a currently valid OMB control number. Public burden for the
collection of this information is estimated to average 45 minutes per response.
Comments regarding this collection of information should be directed to the
Department Clearance Officer, U.S. Department of Justice, Justice Management
Division, Office of the Chief Information Officer, Policy and Planning Staff,
Two Constitution Square, 145 North Street, N.E., Room 2E–508, Washington, D.C.
20530.

OMB No. 1190-0009. Expiration Date: May 31, 2015

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