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Americans with Disabilities Act Title II Grievance Form

  1. Americans with Disabilities Act Title II Grievance Form

    This Grievance Form is established to meet the requirements of the Americans with Disabilities Act of 1990 ("ADA").  It may be used by anyone who wishes to file a complaint alleging discrimination based on disability in the provision of services, activities, programs, and/or benefits by the City of Hollywood.  The City of Hollywood will make all reasonable modifications to ensure that people with disabilities have equal opportunities to our services, programs, and/or activities. If you believe that you have been discriminated against, we respectfully request you complete this form to provide us opportunities for improvement. Please fill out this form completely and then submit. If you need assistance or have questions about this form, please contact the City’s ADA Coordinator: Clarissa Ip, P.E., City of Hollywood ADA Coordinator City Hall, 2600 Hollywood Boulevard, Room 308, Hollywood, FL 33020. Telephone number: 954.921.3915.

  2. Did anyone witness the incident?

    Please select one.

  3. Please provide the name, address and contact information for your witness.

  4. Have attempts been made to resolve the complaint through a City Department?
  5. Please check the box below to confirm *
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