Americans With Disabilities Act (ADA) Grievance Form

2. This form can be completed on this page and submitted when finished at the end, or the form can be printed, completed, and sent to:
   Employee Services, Attn: Alana Thurston, 1100 Simonton Street, Suite 205, Key West, FL 33040, Phone: 305-292-4461, Fax: 305-292-4454. Email: thurston-alana@monroecounty-fl.gov.
4. Additional assistance:
   Contact the County Administrator's Office by phoning 305-292-4441, between the hours of 8:30 a.m. - 5 p.m., if you are hearing or voice impaired, call "711."
6. It is best practice to give consideration to the accommodation sought as required under title II of the ADA; however, alternative methods that achieve effective communication are permissible. The County may comply with the requirements of this section through such means as redesign of equipment, reassignment of services to accessible buildings, assignment of aides to beneficiaries, home visits, delivery of services at alternate accessible sites, alteration of existing facilities and construction of new facilities, use of accessible rolling stock or other conveyances, or any other methods that result in making its services, programs, or activities readily accessible to and usable by individuals with disabilities. The County is not required to make structural changes in existing facilities where other methods are effective in achieving compliance with this section. The County, in making alterations to existing buildings, shall meet the accessibility requirements of Regulation 35.151 in choosing among available methods for meeting the requirements of this section, the County shall give priority to those methods that offer services, programs, and activities to qualified individuals with disabilities in the most integrated setting appropriate. Auxiliary aid requests will be provided at no charge.
8. COMPLAINTANT INFORMATION
10. Name*
12. Address1*
14. City*
15. State*
16. Zip*
18. Email Address*
19. Phone
23. PERSON ALLEGING ADA VIOLATION (if other than the complaintant):
25. First Name
26. Last Name
28. Address1
30. City
31. State
32. Zip
34. Email Address
35. Phone
37. Other contact information:
41. INFORMATION ON ALLEGED VIOLATION
43. Date and time alleged violation occured:*
45. Location of alleged violation:*
47. Description of Alleged Violation*
49. REQUESTED REMEDY (Reasonable accommodation/modification of program and/or service):*
51. (Attach additional information or documentation if necessary)
53. HAS THIS COMPLAINT BEEN FILED WITH THE RESPONSIBLE FEDERAL ENFORCEMENT AGENCY, U.S. DEPARTMENT OF JUSTICE, OR COURT?*

    1. Yes
    2. No
55. If you answered "Yes" to the previous question, please provide the name of the agency or the court, and the contact person's address and phone number, and the date it was filed.
57. Any additional information you wish to provide
61. Date request was received:
63. Name and title of County employee responding to this request:
65. Additional oral or written information requested?

    1. Yes
    2. No
67. If so, describe information:
Leave This Blank:


69. 1. Receive an email copy of this form.
70. Email address

    This field is not part of the form submission.

71. Submit

* indicates a required field