ADA Grievance Form

Post August 8, 2024

An electronic grievance can be filed by completing and submitting the form below.

Today's Date: *

Contact Information

Your Name: *

Address: *

City: *

State: *

Zip Code: *

Phone: *

Email: *

Contact Information of Individual Discriminated Against

Legal Name of Individual Discriminated Against: *

Address: *

City: *

State: *

Zip Code: *

Phone: *

Email: *

Alleged Violation

Date of Occurrence: *

Description of Violation and SCAG Department Involved: *

Requested Action by SCAG to Correct Violation: *

Agency Information

Has Complaint Been Filed With State or Federal Agency?: *

Yes

No

Name of Agency:

Date Filed:

Agency's Contact Person:

Signature of Complainant: *

Date Signed: *

Commands