Form Center

2. Instructions:
   Please complete the form and submit it within sixty (60) business days of any incident to the City of Gainesville's ADA Coordinator.
4. Type of Grievance*

   Check all that apply.

   1. Accommodation Request
   2. Program/Service

   1. Facility Accessbility
   2. Other (Please explain below)
6. Type of Grievance (contd.)
   Space provided for explanation of other type of grievance.
10. Contact Information of Reporting Individual
    Please complete the contact information for the reporting individual.
12. First Name*
13. Last Name*
15. Address*
17. City*
18. State*
19. Zip*
21. Phone Number*
    Phone Number
22. Email Address*
    Email Address
24. Contact Information of Authorized Representative
    Please complete the contact information for the authorized representative of reporting individual, if any.
26. First Name
27. Last Name
29. Address1
31. City
32. State
33. Zip
35. Phone Number
36. Email Address
40. Details of Complaint/Incident
42. Date and Time of Incident*
43. Department/Facility/Location Involved*
45. Describe the incident/complaint with enough detail so the nature of the grievance can be understood.*
47. Resolving Complaint*

    Have attempts been made to resolve the complaint through a City Department?

    1. Yes (If yes, see next item.)

    1. No
49. Resolving Complaint (contd.)
    If yes, please describe the efforts that have been made.
51. Remedy Sought*
    What action do you want taken?
53. File Upload
    Please upload photos or supporting documentation for your grievance.
57. If you need assistance, require an accessible format, or have questions about this form, please contact the ADA Coordinator for the City of Gainesville.
59. City of Gainesville, Attn: Leah Gore, ADA Coordinator 200 S Rusk Street Gainesville, Texas 76240
60. Phone: (940) 668-4590 Fax: (940) 668-4588
61. Email: lgore@cogtx.org
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit

* indicates a required field