City of Wichita - ADA Grievance Procedure Form

Grievance Procedure Form

If you feel that due to a disability you have suffered discrimination in a City facility or program use, please fill out this form completely and click Submit. The form will be sent to our ADA coordinator.

There are two other versions of the form available if you do not wish to use the online form.

Reporting Individual

Reporting Individual Name:
Address:
City, State and Zip Code:
Contact Phone Number:

Person Allegedly Discriminated Against (if Other Than Reporting Individual) Name:
Address:
City, State and Zip Code:
Contact Phone Number:

Program or Facility Alleged to be Inaccessible Name of Program or Facility:
Address:
City, State and Zip Code:
Telephone Number:
When did the alleged discrimination occur?:

Describe the acts of alleged discrimination, or way in which the program or facility is not accessible, providing the name(s) where possible of the individuals who allegedly discriminated.

What were the requests for accommodations or programs, and what was the response?