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2. Under Title II of the Americans with Disabilities Act (ADA), Maricopa County is required to ensure that our facilities, services, and programs are accessible to people with disabilities and in compliance with the ADA.
   
   

   If you feel that you have not been able to access the County government facilities, services, or programs because of accessibility issues, or have been discriminated against based on your disability, please provide the details requested below. Your complaint will be investigated and you will be contacted with the results or additional instructions on how to further proceed. This form and process are designed to provide you with the opportunity to quickly and effectively resolve any issue(s) as they relate to the ADA and Maricopa County.
   
   

   This grievance procedure is solely for facilities, programs, and services owned and/or operated by Maricopa County.
   
   

   If your grievance is related to a non-County owned business (Title III businesses), please contact the U.S. Department of Justice Information Line at 1-800-514-0301 for assistance.

    

4. Section 1. Contact Information
6. First Name*
7. Last Name*
9. Phone Number*
11. Email Address
13. Address
15. City
16. State
17. Zip Code
19. Section 2. Complainant Information
21. Are you filing this complaint on your own behalf?

    1. Yes
    2. No
23. If yes, skip to section 3.
25. If No, please provide the following contact information for the person discriminated against:
27. First Name
28. Last Name
30. Address
32. City
33. State
34. Zip Code
36. Email Address
38. Section 3. Incident Description
40. Date of the alleged discrimination
    Date of the alleged discrimination
42. Location of the alleged discrimination:
44. Explain as clearly as possible what happened and why you believe that you were discriminated against. Describe all of the persons, program and/or services involved.*
46. Section 4. Incident Information
48. Please list any and all witnesses’ names and phone numbers/contact information.
50. Have you discussed your complaint with a County employee?

    1. Yes
    2. No
52. If yes, provide name(s) and position(s)
54. Have you filed your complaint with a federal, state, or local agency; or with a federal or state court?

    1. Yes
    2. No
56. You may attach any written materials or other information you think is relevant to your complaint.

    Allowed types: .gif, .jpg, .jpeg, .png, .doc, .docx, .xls, .xlsx, .rtf, .pdf, .txt

58. By inputting my name below, I affirm that the above is true to the best of my knowledge, information, and belief.
60. Name*
61. Date*
    Date
Leave This Blank:


63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit Submit and Print

* indicates a required field