ADA Complaint Form

First name:
Last name:
Address:
Address 2:
City:
State:
Zip:
Email:
Phone:	( ) - Second three digits Last four digits
Reason for Grievance/Complaint: Please be specific and provide as much information as possible, such as location, date, time, names, etc. :
What do you think could/should be done to resolve this issue? :

This information will be held in confidence unless instructed otherwise by you.

If you have questions about this form, need an accommodation, or a different format, please contact Director of Risk Management, Gregory L. Headley.

Gregory L. Headley
Director of Risk Management
4101 Fulton Parkway
Cleveland, Ohio 44144
216.635.3293
[email protected]