Pleasant Hill, CA · Contra Costa County
Grievance Under the Americans With Disabilities Act
Pleasant Hill residents may use this form to report alleged disability discrimination involving City programs, services, activities, or benefits.
What this form is
Use this form to file a grievance alleging disability discrimination in the City of Pleasant Hill’s programs, services, activities, or benefits. The city asks for the complainant’s contact information, the location and date of the alleged discrimination, and a description of what happened and what action the complainant wants. The form also asks whether an accommodation was requested before the alleged discrimination.
Who needs it
Anyone wishing to report alleged disability discrimination in a Pleasant Hill City program, service, activity, or benefit may file this grievance.
How to submit it
Send the completed form to Ananthan Kanagasundaram, City Engineer, at 100 Gregory Lane, Pleasant Hill, CA 94523, or email [email protected] or fax (925) 676-1125. The procedure says to submit as soon as possible, no later than 60 calendar days after the alleged violation.
About notarization
This grievance form is signed and dated without a notary; it lists no notarized or sworn attachment or related step.
How to submit this form
- 1
Download The Form
Download the Pleasant Hill ADA grievance form.
- 2
Complete The Form
Provide the requested contact information, incident details, and action you would like to see.
- 3
Sign And Date
Sign and date the completed grievance form.
- 4
Submit To The City
Send it to the ADA Coordinator at the listed address, email, or fax as soon as possible and within 60 calendar days of the alleged violation.
Frequently asked questions
- What is the Pleasant Hill ADA grievance form for?
- It is for reporting alleged disability discrimination in Pleasant Hill City programs, services, activities, or benefits.
- How do I submit the ADA grievance form?
- Send it to Ananthan Kanagasundaram, City Engineer, at 100 Gregory Lane, Pleasant Hill, CA 94523, or use the listed email or fax. The procedure says to submit no later than 60 calendar days after the alleged violation.
- What information does the grievance form ask for?
- The form asks for contact details, information about the person allegedly discriminated against, the facility, program, or service, the date and description of the alleged discrimination, and the action requested.
- Do I need a notary for the ADA grievance form?
- No. The form is signed and dated without a notary, and it lists no notarized or sworn attachment or related step.
Need something notarized?
This Grievance Under the Americans With Disabilities Act doesn’t need a notary — but if you have another Pleasant Hill form that does, a commissioned online notary can help.