Complaint Form - Disability Based Discrimination. Please fill out the form below:

1

Complainant Information:

 *

Complainant Information:

Name:

Phone:

Alternate Phone:

Mailing Address:

City:

State:

Zip Code:

Email Address:

Today's Date:

2

Preferred method of contact

Preferred method of contact

Email

Phone

Mail

3

Provide a detailed explanation of the accessibility barrier or discrimination:

 *

Provide a detailed explanation of the accessibility barrier or discrimination:

4

Select each of the following that are applicable to the access barrier or discrimination complaint:

Select each of the following that are applicable to the access barrier or discrimination complaint:

Public Rights-of-Way

Program

Service

Activity

5

provide solution to the complaint:

provide solution to the complaint:

6

Has any other agency been contacted regarding this request?

Has any other agency been contacted regarding this request?

Yes

No

7

If yes, what agency or agencies did you contact?

If yes, what agency or agencies did you contact?

8

If you spoke to an agency or agencies, who were the agents you spoke with?

If you spoke to an agency or agencies, who were the agents you spoke with?

9

Nevada Department of Transportation - External Civil Rights
ADA/504 Program
1263 South Stewart Street
Carson City, NV  89712
Phone: (775) 888-7215
Fax: (775) 888-7235
TTY: (855) 878-6368
Email: adaprogram@dot.nv.gov

1. To receive a copy of your submission, please fill out your email address below and submit.
2. Email Address

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