LKLP Community Action

ADA / Section 504 Program Complaint Form

ADA/Section 504 of the Rehabilitation Act of 1973 forbids denying qualified individuals with disabilities the opportunity to participate in programs receiving federal financial assistance. Use this form to submit a complaint involving alleged discrimination in access to LKLP programs, services, or activities.

Instructions

Fields marked * are required.
You may use the Tab key to move through the form.
If you need help completing this form, contact the ADA/Section 504 Coordinator at (606) 436-8853.
This notice is available in large print, on audio tape, and in Braille upon request.

Section 1: Complainant Information

Full name *

Mailing address *

City *

State *

ZIP code *

Preferred method of contact *

Home phone Email Alt/Cell

Home phone

Email address

Alt/Cell

Type of disability

Select all that apply.

If other, please describe

Attorney Representation for This Complaint (if any)

Attorney full name

Firm name

Address

City

State

ZIP code

Phone

Section 2: Incident Details

Select each item that applies to the denied access of the complainant

Public Rights-of-Way Program Service Activity

Provide a detailed explanation of the denied accessibility incident *

Include dates, location, time, and the names, addresses, and phone numbers of any witnesses.

Section 3: Government, Organization, or Institution Believed to Have Discriminated

Company name *

Street address *

Mailing address (if different from street address)

City *

State *

ZIP code *

Phone

Person complainant spoke with

Title (if known)

Proposed resolution or accommodation

Describe the specific remedy being requested.

Have you filed this complaint with any other federal, state, or local agency, or with any federal or state court? *

Yes No

Agency name

Date

Person/title complaint directed to

Section 4: Signature Authorization & Additional Instructions

By providing a signature below, the complainant acknowledges that the information on this form is true and accurate to the best of their knowledge and accepts that they may be contacted by an LKLP representative regarding this complaint.

Signature *

Date *

Return this form to

LKLP CAC, Inc.
ADA/Section 504 Coordinator
398 Roy Campbell Drive
Hazard, KY 41701

Need help or an alternate format?

This notice is available in large print, on audio tape, and in Braille upon request to the ADA Coordinator.

LKLP does not discriminate on the basis of disability in admission of its programs, services, or activities; in access to them, in treatment of individuals with disabilities, or in any aspect of their operations. LKLP also does not discriminate on the basis of disability in hiring or employment practices.

Questions, complaints, or requests for additional information regarding ADA and Section 504 may be addressed to the ADA/Section 504 Coordinator at the address listed above.