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ADA Grievance Form

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This form has been modified since it was saved. Please review all fields before submitting.

Please fill out the form completely, sign the form, and submit within 60 days of any incident.
Type of Grievance (select any that apply)*
1. Accommodation Request
2. Program/Service
3. Facility Accessibility
4. Other
If you selected "Other", please specify:
Department/Program:
Complaint / Incident Details
Date of complaint/incident:
Date of complaint/incident:
Date of complaint/incident:
Describe the complaint/incident:
Have efforts been made to resolve this complaint through the Department in which the alleged discrimination took place?
1. Yes
2. No
If yes, please describe the efforts that have been made:
Remedy sought:
Contact Information
Reporting Individual
Full Name:
Email Address:
Address:
City:
State:
Zip Code:
Phone Number:
On Behalf of:
(if different than Reporting Individual)
Full Name:
Email Address:
Address:
City:
State:
Zip Code:
Phone Number:
For questions about this form, please contact ADA Coordinator Paul Rudacille at ADA@Charlottesville.gov or call 434-970-3182