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Americans with Disabilities Act (ADA) Complaint/Assistance Form

Please correct the field(s) marked in red below:

CITY OF BELMONT

ADA COMPLAINT/ ASSISTANCE FORM


Please fill out as much of this form as you can. If you need help, tell us, and we would be happy to provide it. If you don’t know the answer to something, please leave it blank.

 

1

Please enter your name

2

Please enter your phone number

3

May we leave a message?

4

Please enter your street address

5

Please enter your email

The City Manager’s Office helps to investigate and resolve disability access or discrimination issues for the City Departments and their Contractors. Access issues usually fall into one of three categories. Please let us know which category best describes your issue:

 

6

Please answer Yes or No

Architectural Access - Is the access problem architectural? -- For example, a wheelchair ramp is needed, braille signage is missing, or accessible counters are too high for wheelchair users.

Please answer Yes or No Architectural Access - Is the access problem architectural? -- For example, a wheelchair ramp is needed, braille signage is missing, or accessible counters are too high for wheelchair users.
7

Please answer Yes or No

Programmatic Access – Is the access problem programmatic? – For example, you cannot get or maintain a City benefit or service because of a disability, or you asked for a reasonable modification of a policy, practice or procedure in order to obtain City benefits or services, but were denied one.

Please answer Yes or No Programmatic Access – Is the access problem programmatic? – For example, you cannot get or maintain a City benefit or service because of a disability, or you asked for a reasonable modification of a policy, practice or procedure in order to obtain City benefits or services, but were denied one.
8

Please answer Yes or No

Communication Access – Does the access problem involve communication? – For example, you need an interpreter, materials in alternative formats, or other auxiliary aids and services in order to have equal access to information and communications for a City benefit, service or activity.

Please answer Yes or No Communication Access – Does the access problem involve communication? – For example, you need an interpreter, materials in alternative formats, or other auxiliary aids and services in order to have equal access to information and communications for a City benefit, service or activity.
9

Which City Department or Contractor does this complaint involve?

10

Please describe the problem you encountered

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Please give us the date of the most recent problem

12

Please give us the location or address of the problem

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Is there a change in policy or procedure you wish to see that would be helpful in solving this problem?

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Do you know the name or position of any of the staff you encountered?

We will provide a copy of this complaint to the appropriate Department Director, who will conduct an investigation. You should receive a written response from the Department within a maximum of 30 business days. If you do not, please contact us at:

 

ADA Coordinator/City Manager
City of Belmont
One Twin Pines Lane, Suite 340
Belmont, CA 94002
(650) 595-7408

  1. To receive a copy of your submission, please fill out your email address below and submit.