ADA Complaint / Grievance Form

Instructions: Use this form to report alleged accessibility issues, discriminatory barriers, or Title II ADA violations concerning Columbus Consolidated Government facilities, programs, services, or activities.

Complainant Information
Complainant Name

First Name
Last Name
Phone
Area CodePhone Number
Email

Address

Street Address
Street Address 2
City	Region
Postal Code	Country

Incident & Accessibility Details
Datetime
Month - Day - Year
Department / Facility Involved
Detailed Description of Alleged Violation / Accessibility Issue:
Requested Remedial Action / Accommodation:

Signature & Submission
Signature
Date
Month - Day - Year
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