Mayor's Office on Disability

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City Programs: ADA Complaint / Assistance Form

Please fill out as much of this form as you can. If you need help, tell us, and we would be happy to provide it. If you don't know the answer to something, please leave it blank.

Name:
Address:
City:		State:		Zip:
Phone (day):
Phone (evening):
Email:
Fax:

Please check if you need a sign language interpreter:

The Mayor's Office on Disability helps to investigate and resolve disability access problems and disability discrimination issues of the City and County of San Francisco. Access issues usually fall into one of two categories. Please let us know which category best describes your issue:

Access Issue Category

	Architectural Access - Please check here if the access problem is architectural -- for example, a wheelchair ramp is needed, accessible bathrooms are not available, or counters and phones are not at the correct height for wheelchair users.
	Programmatic Access - Please check here if the access problem is programmatic - for example, you cannot get or maintain a city benefit or service because of a disability, or you asked for a reasonable modification of a policy, practice or procedure in order to obtain City benefits or services, but were denied one.
	Communication Access - Please check here if the access problem involves communication - for example, you need an interpreter, materials in alternative formats, or other auxiliary aids and services in order to have equal access to information and communications for a City benefit, service or activity.

Which City Department does this complaint involve?
Name of Departmnet involved

If not a City Department, check if this is an entity that receives City funds?

If yes, please provide more information below.

Name:
Address:	Address of City Funded Agency

Please describe the problem you encountered:


Please give us the date of the most recent problem:


Please give us the location of the problem:


Is there a change in policy or procedure you wish to see that would be helpful in solving this problem?

Do you know the name or position of any of the staff you encountered

Names and Positions of Staff Encountered

Name:
Position:
Name:
Position:

Was there anyone else who had the same difficulty, or with whom you would want us to talk in order to get more information?

Names of Other Persons to Contact

Name:
Phone:
Name:
Phone:

     

 

We will provide a copy of this complaint to the appropriate ADA Coordinator, who will conduct an investigation. We may assist in this investigation and will review the results. We will also assist in attempting to resolve the complaint in a manner that is both satisfactory to you and consistent with applicable law. You should receive a written response from the Department within a maximum of 30 days. If you do not, please contact us at (415) 554-6789, TTY: (415) 554-6799.

For additional information, please contact the Mayor's Office on Disability,
401 Van Ness Avenue, Room 300,. San Francisco, CA 94102
Phone: 415.554.6789 voice;
415.554.6799 TTY;
415.554.6159 fax or
email MOD@sfgov.org