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Title II Americans with Disabilities Act (ADA) Complaint Form
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This form has been modified since it was saved. Please review all fields before submitting.
First Name
Last Name
Address1
Address2
City
State
Zip
Phone Number
Phone number where you can be reached between 8 a.m. to 5 p.m.
Is this a TDD number
yes
no
Email
Reason for grievance/complaint, or why you feel you have been discriminated against. Please be specific and provide as much information as possible including date, time, location, names of people present, etc.
What do you think should be done?
Signature
By typing in your name here, you are signing this document.
Date
Date
If you need assistance completing this form or require a different format or other accommodation, please contact the ADA Coordinator at 303.438.6231 or ada@broomfield.org.
Please allow up to 45 days for us to investigate and respond to your complaint.
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