ADA Discrimination Complaint Form

Ada County Human Resources

Please provide the following information necessary to process your ADA discrimination complaint. Assistance is available upon request.

ADA Coordinator
Ada County Department of Administration
200 W Front Street, Boise, ID 83702
Phone (208) 287-7123
FAX: (208) 287-7159
[email protected]
Date*
MM slash DD slash YYYY
Complainant's Name*
Address*
Street Address City State ZIP Code
Phone (Home)*
Phone (Work)
Email*
Person discriminated against (if other that complainant)
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of incident of alleged discrimination
MM slash DD slash YYYY
Location of incident
Employee's Name
Office or Department and Position
Explain briefly and clearly what happened and how you believe you were discriminated against. Indicate who was involved and the corrective action you are seeking*
Please list any witnesses and their contact information.
Witness 1
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Witness 2
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
I certify that to the best of my knowledge and belief that the statement and information on this for are true, accurate and complete.
Complainant's Signature (please type your full name)*
Date*
MM slash DD slash YYYY