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2. Please fill out the form completely, sign the form, and submit within 60 days of any incident.

4. Type of Grievance (select any that apply)*

   1. Accommodation Request
   2. Program/Service
   3. Facility Accessibility
   4. Other
6. If you selected "Other", please specify:
8. Department/Program:

12. Complaint / Incident Details

14. Date of complaint/incident:
    Date of complaint/incident:

    Date of complaint/incident:
16. Describe the complaint/incident:
18. Have efforts been made to resolve this complaint through the Department in which the alleged discrimination took place?

    1. Yes
    2. No
20. If yes, please describe the efforts that have been made:
22. Remedy sought:

26. Contact Information

    Reporting Individual

28. Full Name:
29. Email Address:
31. Address:
33. City:
34. State:
35. Zip Code:
36. Phone Number:

38. On Behalf of:

    (if different than Reporting Individual)

40. Full Name:
41. Email Address:
43. Address:
45. City:
46. State:
47. Zip Code:
48. Phone Number:

50. For questions about this form, please contact ADA Coordinator Paul Rudacille at ADA@Charlottesville.gov or call 434-970-3182

Leave This Blank:


52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field