ADA Grievance Form

Complainant Information

First Name: *

Last Name: *

Street Address: *

Address 2:

City: *

State: *

Zip Code: *

Phone Number: *

Email Address:

Alternate Contact Person - An alternate contact is NOT required

First Name:

Last Name:

Street Address:

Address 2:

City:

State:

Zip Code:

Phone Number:

Email Address:

Please Complete the Following

Nature of Disability: *

Date of Alleged Discrimination: *

Time of Alleged Discrimination: *

Please describe the particular way in which you believe you have been denied the benefit, service, program, or activity of the Superior Court, or have otherwise been subject to discrimination as a person with a disability by the Superior Court: *

Please state, if known, the names or positions of any Superior Court employees involved in the incident, as well as names, addresses and telephone numbers of any witnesses to any such incident, if necessary:

Security Code *

Norma Quiroz
ADA Coordinator
Contact the ADA Office

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This page was last updated on: Thursday, June 29, 2023 12:08 PM