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Home My WebLink About2022 ADA Grievance FormContinued Rev. 08/2022 City of Palm Desert Title II of the Americans with Disabilities Act Section 504 of the Rehabilitation Act of 1973 GRIEVANCE FORM Reporting Individual: _____________________________________________________________________ Address: ________________________________ City: _______________ State: _____ Zip code: _______ Telephone number: ________________________ Email address: ________________________________ This section to be completed only if the aggrieved person is not the individual completing this form. Person(s) affected if other than reporting individual: Address: ________________________________ City: ____________ State: ____ Zip code: __________ Telephone number: ________________________ Email address: _______________________________ Program/Facility for which an accommodation or barrier removal has been requested: _________________________________________________________________________________________ _________________________________________________________________________________________ When did you first request the accommodation or barrier removal? ______________________________ ________________________________________________________________________________________ Describe the situation or way in which you are dissatisfied with how the City responded to your request for accommodation or barrier removal: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Attach additional sheets, if necessary. Rev. 08/2022 Have efforts been made to resolve this complaint through the ADA Coordinator? YES NO If yes, what were the results? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ Additional space for comments: _______________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Signature: __________________________________ Date: ______________________________ Send to: City Clerk 73-510 Fred Waring Dr Palm Desert, CA 92260 760-346-0611 (phone) 760-340-0574 (fax) cityclerk@cityofpalmdesert.org