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ADA Complaint Form

  1. 1. Name of the person filing this complaint:

  2. 2. Name of person discriminated against (if other than person filing). If the person discriminated against is age 18 or older, we will need that person's signature on this complaint form and the consent / release form before we can proceed with this complaint. If the person is a minor, and you do not have the legal authority to file a complaint on the student's behalf, the signature of the child's parent or legal guardian is required.

  3. 3. Government entity which you believe has discriminated:

  4. 4. The regulations DCTS enforces prohibit discrimination on the basis of race, color, national origin, sex, disability, age or retaliation. Please indicate the basis of your complaint:

  5. Date:

  6. 7. If this date is more than 180 days ago, you may request a waiver of the filing requirement. I am requesting a waiver of the 180-day time frame for filing this complaint. Please explain why you waited until now to file your complaint.

  7. 9. If the allegations contained in this complaint have been filed with any other Federal, state or local civil rights agency, or any Federal or state court, please give details and dates. We will determine whether it is appropriate to investigate your complaint based upon the specific allegations of your complaint and the actions taken by the other agency or court.

  8. 10. If we cannot reach you at your home or work, we would like to have the name and telephone number of another person (relative or friend) who knows where and when we can reach you. This information is not required, but it will be helpful to us.

  9. 12. By submitting this form, you are confirming the information provided is true to the best of your knowledge and you are giving us authorization to investigate your claim.

  10. Leave This Blank:

  11. This field is not part of the form submission.