This form is for City-run programs and activities, City services, and City-owned buildings.   For private businesses, private employers, or if you are a City of Warren employee, please contact the DOJ, the EEOC, or the City of Warren Employee Portal respectively.

City of Warren ADA Complaint Resolution and Reasonable Accommodation Request

Name

First Last

How would you like to be contacted:

Mail

Email

Telephone

Address

Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code

Email

Phone

I am submitting:

a request for reasonable accommodation

a complaint

an allegation of discrimination or retaliation

My complaint/accommodation request/allegation of discrimination or retaliation relates to:

a physical barrier (City-owned property)

a City service, program, or meeting

the City website

disability-related discrimination or retaliation Incident date(s):

Compliment/Suggestion/Question

Reasonable Accommodation

Accommodation requested (please be specific).

Event details (date, time, and name of event).

This accommodation is being requested because I (or the person submitting this form on my behalf) have a ADA-covered disability that prevents me from participating in the above-listed event.

check this box

Complaint

Please explain the nature of your complaint and what resolution you seek:

Disability-related discrimination or retaliation:

Please explain the circumstances of the alleged discrimination or retaliation, including the persons involved, potential witnesses, and evidence.

Compliment/Suggestion/Question

Signature

Date

MM slash DD slash YYYY

CAPTCHA

Submit

This online form may also be printed and mailed or submitted in person to the City of Warren ADA Coordinator, c/o Warren City Attorney’s Office, One City Square, Suite 400, Warren, Michigan 48093.

Please direct any questions about this form to the ADA Coordinator by email adawarren@cityofwarren.org or by phone (586) 574-4671.