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2. ADA Complaint Form

   In accordance with the requirements of Title II of the Americans with Disabilities Act (“ADA”) of 1990 and Section 504 of the Rehabilitation Act of 1973, the City of Wray (“City”) will not discriminate against qualified individuals with disabilities on the basis of disability in its provision of public facilities, services, programs or activities. 

   If you feel you have been discriminated against on the basis of a disability through the City of Wray's provision of a public facility, service, program or activity (pursuant to the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973), please complete this ADA Complaint Form.    

   If you need assistance in completing this form, including sign language assistance, documents in Braille or other ways of making information and communications accessible, please contact the City’s ADA Coordinator via email, at adacoordinator@cityofwray.org, or by calling 970.332.4431 

4. PLEASE RESPOND TO ALL QUESTIONS TO THE BEST OF OUR KNOWLEDGE
6. 1. Complaintant
8. Your Name
10. Address
12. City
13. State
14. Zip Code
16. Phone Number
17. Email
19. 2. Person discriminated against (if someone other than you, complainant)
21. Name
23. Address
25. City
26. State
27. Zip Code
29. Phone Number
30. Email
32. 3. Which City of Wray public facility, program, service or activity is the complaint about (complete all that apply to this complaint, otherwise, leave blank)
34. City Facility Name:
35. City Program, Service or Activity
37. City Employee(s) Involved
39. 4. Date of incident (resulting in complaint)
    4. Date of incident (resulting in complaint)
41. 5. Location of incident (resulting in complaint)
43. 6. In your own words, describe the circumstances surrounding this complaint. Please provide as many details as possible, such as time of day, specific actions, events, interactions, names and job titles, who said what, who was present at the time, etc.
45. Circumstances surrounding this complaint
47. 7. Were there any witnesses to the incident?

    1. Yes
    2. No
49. 8. Have any efforts been made to file or resolve this complaint through the internal grievance procedures of any City of Wray department?

    1. Yes
    2. No
51. 9. Have you filed a complaint about this same incident with any other agency or court? If so, fill in the organization's name and contact person.
53. Federal Agency Name
54. Federal Agency Contact Person
56. Federal Court Name
57. Federal Court Contact Person
59. State Agency Name
60. State Agency Contact Person
62. State Court Name
63. State Court Contact Person
65. City/Local Agency Name
66. City/Local Agency Contact Person
68. City/Municipal Court Name
69. City/Municipal Court Contact Person
71. Other - Please provide the full contact information for the person with the "other" agency or court
73. Name
74. Affiliation
76. Address
78. City
79. State
80. Zip Code
82. Phone Number
84. Date filed
    Date filed
86. 10. Type your name in the space below to provide an electronic signature.
88. 11. Today's date
    11. Today's date
90. 12. In order to receive a copy of this complaint, please enter your email below.

92. The City's ADA Coordinator will notify you when your complaint has been received. If you do not receive confirmation within 2 weeks, please call or email the City's ADA Coordinator at 970.332.4431 or adacoordinator@cityofwray.org.

Leave This Blank:


94. 1. Receive an email copy of this form.
95. Email address

    This field is not part of the form submission.

96. Submit

* indicates a required field