Request for ADA Grievance Resolution

Today's Date*

Date of Complaint*

Name of Individual (Grievant)*

Location of Complaint*

Names of Parties Involved*

Nature of Complaint Detailing Specific Events*

You may attach digital versions of any documentation that may support your grievance below.

Prior Attempts To Resolve*

Please indicate any previous efforts to resolve your complaint including dates and parties involved.

Documentation Upload

Drop files here or

Accepted file types: jpg, pdf, Max. file size: 15 MB.

If you have any documentation that may support your grievance, please upload here.

.JPG and .PDF files are accepted, up to 15 MB in size. If you have more documentation and/or do not have digital copies, you may bring it to:

ADA Coordinator
City of Kingsport
415 Broad Street
Kingsport, TN 37660

Print Name*

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Your Email

If you provide an email address, a .pdf copy of this request will be emailed to you.

Your Phone*

Signature*

By checking this box and submitting this form, I certify all info is true and correct to my knowledge.*

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