ADA Complaint Form for Denial of Reasonable Accommodation

ADA Complaint Form for Denial of Reasonable Accommodation

This form is provided in accordance with the Americans with Disabilities Act (ADA) and City of Lenexa Administrative Policy AD08-E and is to be completed by or on behalf of a person who has been DENIED by the City ADA Coordinator a reasonable accommodation due to a qualifying disability. Complete this form in its entirety, as it constitutes your formal complaint against the City of Lenexa.

Complainant Name:

Address:

Phone:

Email:

Name of Person Completing the Form:

Phone Number of Person Completing the Form:

Please describe the denial by the City of a reasonable accommodation, or your disatisfaction with the offered accommodation(s), including but not limited to location, date of denial or dissatisfaction, persons involved, etc.

If accommodations were offered by the City, please describe why they would not be feasible in your case:

E-Signature:

Date:



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