ADA Grievance Form 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: * CAPTCHA Card View Options Two Column SHARE THIS PAGE Related Links
