TOWN OF CORTE MADERA
ADA POLICY
POLICY ON REPORTING AND
RESOLVING AMERICANS WITH DISABILITIES ACT (
GRIEVANCES AND ACCESSIBILITY
COMPLAINTS WITHIN THE TOWN
ADA GRIEVANCE AND
ACCESSIBILITY COMPLAINT FORM
Notes:
1.
Please
refer to the attached instructions when completing this form.
2.
Please
write legibly in pen (not pencil) or type the response.
3.
If you
are the proxy or filling this form on behalf of another individual, please
indicate in Section III of the form.
4.
If
you need assistance in completing this form, please contact the Corte Madera
Department of Public Works at (415) 927-5057.
1. Sidewalk
2. Curb ramp
3. Traffic control and devices
4. Parks and recreational facilities
5. Town’s services
6. Town’s activities
7. Parking
8. Other ____________________________________
Section II. Complainant Information
A. Name: _________________________________________
B. Address: _________________________________________
_________________________________________
_________________________________________
C.
Telephone: _________________________________________
D.
Email: _________________________________________
Section III. Association/Group or Proxy Information
Association/Group
Proxy (Individual)
A. Name: _________________________________________
B. Address: _________________________________________
_________________________________________
_________________________________________
E.
Telephone: _________________________________________
F.
Email: _________________________________________
Section IV. Nature and/or description of Grievance
or Complaint
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Section
V. Sketch or Location of Complaint
Section
VI. Recommendation by Complainant
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Section
VII. Signature and Date
__________________________________ ____________________