City of Shakopee

ADA Grievance Form

Americans with Disabilities Act (ADA) Grievance Form

The City of Shakopee is committed to ensuring equal access to all programs, services and activities in accordance with the Americans with Disabilities Act. Individuals who believe they have experienced a barrier to access or discrimination based on disability may submit an ADA grievance using this form. Please provide as much detail as possible so the city can review and respond promptly.

Contact Information of Person Filing the Grievance

Name*

Address

Phone

Email*

Best way to reach the person filing this grievance*

Phone

Other

Other Method of Contact

Person Affected (If Different From Above)

Name*

Relationship to complainant*

Phone or email (optional)

Location of the Issue

Department, facility, location, service or program involved*

Address of the issue*

Description of the Issue

Please describe the barrier, incident or concern*

Requested Resolution

What action or change would resolve this issue?*

Supporting Documentation (Optional)

Please list and attach any documents, photos, or other materials related to the grievance:

Signature

Signature*

Services

Forms

All of Shakopee