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2. Purpose of the Form

   This form is designed to provide you with the opportunity to effectively resolve any ADA or Accessibility issues you may have with the City and County of Broomfield as is outlined in Title II Americans with Disabilities Act.

   You can use this form to file an ADA or digital accessibility request or accommodation or an instance of discrimination.

   If you need assistance completing this form or require a different format or other accommodation, please contact the ADA Coordinator at ada@broomfield.org or by calling 303-464-5176.

4. Notice of Procedure for a Request

   A notice of receipt shall be mailed to the requestor by email or regular mail within five days of receipt of the grievance or request. The ADA Coordinator shall begin an investigation into the merits of the grievance or request within 30 days.

   The ADA Coordinator shall prepare a written decision after full consideration of the grievance or request merits, no later than 30 days following the receipt of the grievance or request.

8. First Name of Requestor*
9. Last Name of Requestor*
11. Street Address of Requestor*
13. Address Addition, if needed
15. City*
16. State*
17. Zip Code*
19. Phone Number of Requestor*

    This phone number needs to be one where you can be reached between 8 a.m. to 5 p.m.

20. Is this a TDD number?*

    1. Yes
    2. No
22. Email of Requestor*
26. Describe the reason for grievance or complaint and/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. For a digital request, please provide the URL of the web page on which you are having the issue or name of the specific document.  

28. What do you think should be done?*
30. Signature of Requestor*

    By typing in your name here, you are signing this document.

31. Date of Submission*
    Date of Submission
Leave This Blank:


33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field