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ADA Grievance Form
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Steps
1.
Step One
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2.
Step Two
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Step One
City of Des Peres ADA Grievance Form
PLEASE complete each section of this form to the best of your ability. For assistance with this form, or for information about the program accessibility, please call (314) 835-6157 Voice or please use Relay Missouri 1-800-735-2966 TDD.
ADA Grievance Procedure Process
ADA Procedure Process
Please view the hyperlink to the Des Peres ADA Grievance procedure process and pdf form if you prefer to print out and mail in. Please view for full procedure information. *Adobe or Adobe Reader is required to view this link.
First Name
*
Last Name
*
Address1
*
Address2
City
*
State
*
Zip
*
Are you filing this inquiry:
*
(Check all that apply)
A. On Behalf of yourself as a person with a disability?
B. On Behalf of a family member or ward who has a disability?
C. As a person associated with another who has a disability?
D. As an interested person?
If you checked B. above, PLEASE describe your relationship.
Limit of 30 characters. Must be only letters.
ABOUT YOUR INQUIRY
*
Name of program, service, activity, park or facility involved:
Location
Date and time of occurrence you believe was discriminatory or unfair:
Continue
Step Two
WHAT HAPPENED?
Please describe in your own words the action(s) by an employee(s), the rules or policy, the service(s) or the condition of a park, area, facility or structure which you feel is discriminatory or unfair. It is not necessary to refer to laws, regulation, ordinances, or policies in your description.
HOW CAN THE PROBLEM BE CORRECTED?
PLEASE describe the actions, which you feel need to be taken to address the problem.
IS THERE A DEALINE?
Must this problem be addressed before a program begins or an event occurs? PLEASE identify any date, which you feel is important to the problem.
PLANNING A MEETING
The City may need to contact you to schedule a meeting to discuss your complaint. The meeting may occur within fifteen (15) calendar days from the date your inquiry is received.
Do you request an accommodation during the meeting? If yes, please describe:
When are you most available?
Check two (2)
M-F 9:00 -11:00 A.M.
M-F 2:00 - 5:00 P.M.
M-F after 5:00 P.M.
Sat 9:00 A.M. - Noon
Other
Please tell us a time that is more accommodating if none of the above times work.
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