ADA Grievance Form

Are You the Complainant Yes No Please select at least one option

Full name of Person Preparing Complaint

Relationship to Complainant

Complainant First Name This field is required

Complainant Last Name This field is required

Email Address This field is required

Phone Number This field is required

Street Address This field is required

City This field is required

State This field is required

Zip Code This field is required

Please provide a complete description of the specific grievance or complaint: This field is required

Please specify any location(s) related to the grievance or complaint (address or name of facility): This field is required

Please state what you think should be done to resolve the grievance or complaint: This field is required

Please type your full name here to confirm the information above This field is required

Upon request, reasonable accommodation will be provided in completing this form, or copies of the form will be provided in alternate formats. Contact Wendy DeVall at 6201 Florida Blvd., Baton Rouge, LA 70806, via telephone 225-272-9200 ext. 1380 or email: wendy.devall@brec.org