ADA Grievance Form

Grievances submitted by an individual alleging discrimination under the ADA must be submitted directly to the ADA Coordinator no later than 60 calendar days after the occurrence of the alleged incidents of discrimination. This form is for use by members of the public only. Current City of Arlington employees who feel they have been discriminated against must contact the Human Resources Department for assistance.
  • Click here if you would prefer to download a printable version of this form.
  • Contact Information

    Name and contact information of person submitting grievance


















  • Person(s) Allegedly Discriminated Against

    Please provide the name and contact information of the person allegedly discriminated against, if other than person submitting grievance


















  • Incident Details

  • :

  • Name or address of City facility or park where the incident occurred


  • Online Submission Notification

    All forms submitted online are sent directly to the City of Arlington ADA Coordinator for action.

    A written response to your grievance will be provided no later than 21 days from receipt of the grievance.