ADA Complaint Form - Fairfield County Transit

The Americans with Disabilities Act of 1990 (ADA) prohibits discrimination and ensures equal opportunity and access for persons with disabilities for a variety of activities of daily living. The Federal Transit Administration requires that "No qualified person with a disability shall, solely by reason of his disability, be excluded from participation in, be denied the benefits of, or otherwise be subjected to discrimination under any program or activity that receives Federal financial assistance administered by the U.S. Department of Transportation."

Note: The following information is necessary to assist us in processing your complaint. Should you require any assistance or reasonable modifications in completing this form, call 740-681-5086.

1. Complainant Contact Information

Name

Address

City

State

Zip Code

Home Phone

Work Phone

2. Person discriminated against (if other than the complainant)

Name

Address, City, State, Zip Code

3. Incident Details

Reason(s) you believe the discrimination took place:

Date of alleged incident (MM/DD/YYYY):

Describe the alleged discrimination. Explain what happened and who you believe was responsible. (Attach additional sheets if necessary):

4. Previous Filings

Have you filed this complaint with any other federal, state, or local agency; or with any federal or state court?

Yes

If yes, check all that apply

Federal Agency

Federal Court

State Agency

State Court

Local Agency

Please provide contact information for the agency/court where the complaint was filed:

Complainant's Signature

Date