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2. 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.

4. First Name
5. Last Name
7. Address1
9. Address2
11. City
12. State
13. Zip
15. Telephone Number
16. Email Address
18. Contact information for Authorized Representative of Complainant (if any)
20. Telephone Number
21. Email Address
23. Address1
25. Address2
27. City
28. State
29. Zip
31. Date of Incident
32. Location of Incident
34. Please describe the situation or way in which you feel the services, programs and/or activities were inaccessible or discriminatory. Please provide the name(s) of the individuals who were involved in the situation.
36. Please describe the requested action to resolve the complaint.
38. Did anyone witness the incident?

    1. Yes
    2. No

    Please select one.

39. Witness Contact Information

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

41. Please provide any additional information you would like for us to know.
43. Have attempts been made to resolve the complaint through a City Department?

    1. Yes
    2. No
44. Please describe the efforts that have been made.
46. Please check the box below to confirm *

    1. By checking this box I am acknowledging this Electronic Signature as the Complainant and/or Authorized Representative
47. Date and time of complaint filing*
    Date and time of complaint filing

    Date and time of complaint filing
Leave This Blank:


49. 1. Receive an email copy of this form.
50. Email address

    This field is not part of the form submission.

51. Submit

* indicates a required field