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2. Title II ADA Grievance Form

   The City of Warrenville ensures that no person or groups of persons shall, on the grounds of race, color, sex, religion, national origin, age, disability, retaliation or genetic information, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any and all programs, services, or activities administered, its recipients, sub-recipients, and contractors.  To request an accommodation and/or an alternate format or language, please contact the Assistant City Administrator/ADA 504 Coordinator, at 630-836-3050.

   Instructions: Please complete and email this form to the City within 60 calendar days of any incident.

4. Reporting individual:

   Please provide as much information about the grievance as possible. The grievant is not required to answer all questions, however, the City may require additional information in order to respond to the grievance.

6. Type of Grievance (check all that apply)*

   1. Accomodation request
   2. Program/service
   3. Facility accessibility
   4. Other (please explain):
10. Reporting individual:
14. First Name
15. Last Name
17. Address1
19. Address2
21. City
22. State
23. Zip
25. Phone:
26. Alternate phone:
28. Email:
30. 3. Authorized Representative of Reporting Individual (if any):
32. First Name
33. Last Name
35. Address1
37. Address2
39. City
40. State
41. Zip
43. Phone:
44. Alternate phone:
46. Email:
48. Details of complaint/incident
50. Date/Time of Incident:
52. Department/Facility/Location Involved:
54. Describe the incident/complaint with enough detail so the nature of the grievance can be understood:
56. Have attempts been made to resolve the complaint through a City Department? If yes, please describe the efforts that have been made:
58. Remedy Sought. What action do you want taken?
60. Thank you.

    If you need assistance, require an accessible format or language, or have questions about this form, please contact the City’s ADA/504 Coordinator:

    Assistant City Administrator/ADA 504 Coordinator

    Phone: 630-836-3050

    TTY: 711                                                                

    Email: adacoordinator@warrenville.il.us

    Address: 3S258 Manning Avenue, Warrenville, IL 60555

     

Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit

* indicates a required field