INITIAL COMPLAINT OF ADA TITLE II NONCOMPLIANCE FORM

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R ichard S. K eesecker
                         INITIAL COMPLAINT OF ADA TITLE II NONCOMPLIANCE FORM
B oard C hair

Tracy Salvagno
B oard V ice C hair

Jam es W . B row n
B oard M ember
                         Date: ___________________________________________________________
Jud ith E . Ferro
B oard M ember

M ark G oldsm ith
B oard M ember           Name: __________________________________________________________
Tim O ’R ourke
B oard M em ber

D r. Joel Schoening
B oard M em ber
                         Street Address: __________________________________________________
R ichard W illson
E xecutive D irector
                         City: ___________________ State: ______ Zip Code: _________________



                         Phone (day): __________________ (evening):___________________________



                         Email: __________________________________________________________



                         Preferred Method of Contact:

                                      Email
                                      Phone


                         Please specify the Authority staff members or program responsible for the
                         noncompliance for which you would like to lodge a complaint:
Initial Complaint

1. Please describe the problem you encountered:




2. Date of the alleged violation:



3. Location of the problem:




4. Please provide, when possible, the names of any individuals at the Authority involved
in the problem you encountered:




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5. What change would you wish to see that would be helpful in solving this problem:




To include more information, please attach additional sheets as necessary.




Thank you for completing this form. Your complaint will be addressed within 30
business days. Should you be unsatisfied with the response to your complaint you may
appeal to the ADA Title II Coordinator, Teddi Garrision, 301-791-3168 extension 214,
within 10 business days of receiving the response. For information on the Request
Process, Initial Complaint Process and/or Appeal Procedure, please visit
http://www.hawc-link.org or call 301-791-3168.




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