Irvine, CA · Orange County
Incident/Contact Report ADA Title II and Title VI Non-Discrimination Grievance Form
Visitors, residents, and members of the public can use this optional form to report an incident involving an ADA Title II or Title VI discrimination grievance.
What this form is
This optional form lets visitors, residents, and members of the public report an incident involving an alleged discrimination grievance under ADA Title II or Title VI. It asks for contact details, incident date, time and location, the basis and description of the grievance, requested corrective action, witness or employee information, and relevant police or fire report details. It is not for employment-related issues.
Who needs it
Visitors, residents, or members of the public who want to report an incident involving an ADA Title II or Title VI discrimination grievance can use this optional form.
How to submit it
Submit it to the city department named on the form; check the city website for current contact details.
About notarization
This form is signed and dated without a notary; the document does not identify any notarized or sworn attachment or related step.
How to submit this form
- 1
Download the Form
Download the Incident/Contact Report ADA Title II and Title VI Non-Discrimination Grievance Form.
- 2
Complete the Form
Fill in the applicable contact and incident details, describe the grievance, and state the corrective action you would like to see.
- 3
Gather Relevant Details
Include any witness or city employee information and police or fire report details, if applicable.
- 4
Sign and Submit
Sign and date the form, then submit it to the city department named on the form.
Frequently asked questions
- Who can use the Irvine grievance form?
- The form is optional for visitors, residents, and the public. It is not for employment or employee-related issues.
- What information does the form ask for?
- It asks for contact details, incident information, the reason for the grievance, requested corrective action, and any witness, employee, police report, or fire report details that apply.
- Do I need a notary for the Irvine grievance form?
- No. The form calls for the grievant's or authorized representative's signature and a date, and identifies no notarized or sworn attachment or related step.
- How do I submit the Irvine grievance form?
- Submit it to the city department named on the form. The form does not provide submission contact details, so check the city website for current information.
Need something notarized?
This Incident/Contact Report ADA Title II and Title VI Non-Discrimination Grievance Form doesn’t need a notary — but if you have another Irvine form that does, a commissioned online notary can help.