Americans with Disabilities (ADA) Issues

In accordance with Title II of the Americans with Disabilities Act (ADA), The City of Warren will not discriminate against qualified individuals on the basis of disability in their programs, services, or activities.

This form may be used to file a complaint with the City of Warren based on violations of Title II of the Americans with Disabilities Act (ADA). You are not required to use this form; a letter that provides the same information may be submitted to file your complaint. Complaints should be filed within 180 days of the alleged discrimination. If you could not reasonably be expected to know the act was discriminatory within 180-day period, you may have 60 days after you became aware to file your complaint.

If you need assistance completing this form, please contact Human Resources, via phone at 586-574-4670, or by fax at 586-574-0770.

CITY OF WARREN AMERICANS WITH DISABILITIES ACT COMPLAINT FORM

Name

First Last

Date

Address

Street Address Address Line 2 City State ZIP Code

Phone (Home)

Phone (Work)

Individual(s) discriminated against, if different than above

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone (Home)

Phone (Work)

Please explain your relationship with the individual(s) indicated above

Name of agency and department or program that allege discriminated

Agency or department name

Name of individual (if known)

Address

Street Address Address Line 2 City State ZIP Code

Date(s) of alleged discrimination

Start Date and End Date

ALLEGED DISCRIMINATION: Explain: Please explain as clearly as possible what happened. Provide the name(s) of witness(es) and others involved in the alleged discrimination. (Attach additional sheets, if necessary, and provide a copy of written material pertaining to your case).

Signature

Date

CAPTCHA

For questions please contact Human Resources, Diversity Coordinator, City of Warren,
One City Square, Suite 410, Warren, Ml 48093; Phone 586-574-4670; Fax 586-574-0770 or
email to Caitlin Murphy (cmurphy@cityofwarren.org)

The AMERICANS WITH DISABILITIES ACT (ADA) SURVEY RECOMMENDATION AND COMMENT FORM is also available to be filled out.

Note: The City of Warren prohibits retaliation or intimidation against anyone because that individual has either taken action or participated in action to secure rights protected by policies of the City. Please inform the Human Resources Director if you feel you were intimidated or experience perceived retaliation in relation to filing this complaint.