Complaint Form—Title II of The Americans with Disabilities Act

Documents

Below are links to document versions of the ADA Complaint Form. Please fill out this form completely, in black ink or type, sign and return to:

Donald Brand, Office of ADA Coordinator
111 West Chesapeake Avenue, Room 105
Towson, Maryland 21204

ADA Complaint Form (Word)
ADA Complaint Form (PDF)

Online Form

Instructions: Please fill out this form completely. When finished select the "Submit" button to begin the complaint process.

Fields marked with >> are required.

Complainant Information

Complainant >>

Address >>

Telephone >>

Email >>

If your complaint involves a specific event, when did the incident occur?

Describe in detail the event or situation for which you are seeking ADA relief. Provide names, if appropriate, of individuals who were involved.

If this is a general request for an accommodation, describe the functional limitations caused by your disability for which you are requesting this accommodation.

Describe any accommodations that you believe would minimize or eliminate the barriers to your participation in the County’s services, activities, programs, or benefits:

I will need an accommodation to meet with the ADA Coordinator >>

Yes No

If “yes,” the accommodation I will need is:

Signature or Initials >>

Date >>

Revised June 14, 2017

Office of the ADA Coordinator

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Baltimore CountyGovernment

Complaint Form—Title II of The Americans with Disabilities Act

Documents

Online Form

Office of the ADA Coordinator

Baltimore County Government

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