City of Coral Springs, Florida - Title II ADA Grievance

City of Coral Springs, Florida - Title II ADA Grievance

Please complete and sign within 60 calendar days of any incident.
Must be 18 years or older to complete this form. If under 18, a parent or guardian must fill it out on your behalf.
The City of Coral Springs ensures that no person or group shall, on the grounds of race, color, sex, gender, religion, national origin, age, disability, retaliation, genetic information, or any other protected characteristic, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any and all programs, services, or activities administered by the City or its recipients, sub-recipients, and contractors. To request an accommodation or an alternate format of this document, please contact Yuu Soubra, ADA/504 Coordinator, at 954-344-1144 (Office), or 711 (Relay).
Type of Grievance*

Reasonable Modification RequestProgram/Service/ActivityFacility AccessibilityOther
Is there an authorized representative of reporting individual filling out this form*

YesNo
Reporting Individual
Reporting Individual Name*

First NameLast Name
Reporting Individual Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reporting Individual Phone Number*
Add your best contact to reach you.
Reporting Individual E-mail*
example@example.com
Authorized Representative of Reporting Individual
Authorized Representative Name*

First NameLast Name
Authorized Representative Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Authorized Representative Phone Number*
Add your best contact to reach you.
Authorized Representative E-mail*
example@example.com
Date and time of incident*

MonthDayYear
Date
Hour MinutesAM/PM Option
Department or facility of incident*
Location of incident*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Describe the incident/complaint with enough detail so the nature of the grievance can be understood*
Have attempts been made to resolve the complaint through a City Department*

YesNo
Please describe the efforts that have been made*
Requested Resolution: Please describe the action or outcome you are seeking*
By typing my name in the below space, I am electronically signing this form. By signing this electronic signature certifies the information to be true, accurate, and complete.*

First NameLast Name
The City will review and respond to your ADA grievance within 30 to 90 days from the date it is filed. The timeframe depends on the nature and complexity of the case. If you need assistance completing this form, require an accessible PDF format, or have any questions, please contact the City’s ADA/504 Coordinator at:

Physical Address:
Yuu Soubra
ADA/504 Coordinator
Employee Engagement and Inclusion Manager
9500 West Sample Road
Coral Springs, FL 33065

Phone: 954-344-1144
Relay: 711
Email: ysoubra@coralsprings.gov
Should be Empty:

City of Coral Springs, Florida - Title II ADA Grievance

Must be 18 years or older to complete this form. If under 18, a parent or guardian must fill it out on your behalf.

Reporting Individual

Authorized Representative of Reporting Individual