ADA Grievance Form

The ADA Grievance Form allows individuals to file a complaint, in accordance with ADA requirements, alleging discrimination on the basis of disability in the provisions of services, activities, programs or benefits by the Kenai Peninsula Borough.

Reporting Individual

Name(*)

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Mailing Address(*)

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City(*)

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State(*)

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Zip(*)

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Email(*)

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Phone

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Cell Phone

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Fax

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Authorized Representative of Reporting Individual

Name(*)

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Mailing Address(*)

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City(*)

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State(*)

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Zip(*)

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Email(*)

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Phone(*)

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Cell Phone

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Fax

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Detail of Violation

Type of Grievance (check all that apply)

Accommodation Request

Program/Service

Facility Accessibility

Other

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Please Explain(*)

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Date and Time of Incident(*)

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Department/ Facility/ Location Involved(*)

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Describe the Violation(*)

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Have attempts been made to resolve the violation through a Borough Department? If yes, please describe the efforts that have been made.

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What do you recommend as a solution?

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I certify under penalty of perjury, that the foregoing statements are true. I further acknowledge that by typing my initials below I intend to fully sign this document.

Type your initials to sign(*)

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Upload additional information as necessary. If you need assistance, require an accessible format, or have questions about this form please contact the Kenai Peninsula Borough ADA Coordinator at [email protected] or 907-714-2160.

Attachment (5MB Max)

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Prove you're not a bot.(*)

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Clerk's Office

ADA Grievance Form