This grievance form is solely for facilities, activities, programs and services owned and/or operated by Larimer County, Colorado.

If you are a county employee or job applicant wishing to file a complaint of disability discrimination, do not use this form.  The county’s personnel policies and procedures govern employment related complaints of disability discrimination.

If your grievance is related to a non-County owned business (Title III businesses), please contact the U.S. Department of Justice Information Line at 1-800-514-0301 for assistance.

INSTRUCTIONS:  Please print clearly or type your answers, if possible.  If you need help due to your disability in completing this grievance form, you may contact the ADA Coordinator at accessibility@larimer.org or at telephone (970) 498-5967

This form should be submitted to the ADA Coordinator as soon as possible, but no later than 90 calendar days after the alleged violation.

Options to submit this grievance form:

  1. Print Grievance Form and submit by email:  accessibility@larimer.org
     
  2. By U.S. Mail to:  
    Donna J. Notter
    Larimer County ADA Coordinator
    200 West Oak Street, Suite 4000
    PO Box 1190
    Fort Collins, CO 80522-1190
     
  3. Or complete and submit online below:
Your Name and Contact Info
Completed on behalf of the following:
Complaint Information
Address of Department
Phone Number of Department
:

Witness Information

Provide up to two additional witnesses
First Witness
Second Witness
Evidence and Documentation

Please list and provide any physical evidence, written or recorded documents, or any other information that directly supports your specific claim.  You may also attach photographs or other documents in support of your claims.

You may also attach photographs or other documents in support of your claims. Up to 4 attachments supported
Files must be less than 30 MB.
Allowed file types: gif jpg jpeg png tif txt rtf pdf doc docx ppt pptx xls xlsx avi mov mp3 wav gz tar zip.
Files must be less than 30 MB.
Allowed file types: gif jpg jpeg png tif txt rtf pdf doc docx ppt pptx xls xlsx avi mov mp3 wav gz tar zip.
Files must be less than 30 MB.
Allowed file types: gif jpg jpeg png tif txt rtf pdf doc docx ppt pptx xls xlsx avi mov mp3 wav gz tar zip.
Files must be less than 30 MB.
Allowed file types: gif jpg jpeg png tif txt rtf pdf doc docx ppt pptx xls xlsx avi mov mp3 wav gz tar zip.

Note: Parent or Legal Guardian may sign on behalf of minor child.  Legal Guardian, Power of Attorney or equivalent may sign on behalf of adult – documentation is required.

 

By signing and submitting this form, you certify that to the best of your knowledge this information is true and correct.

 

Signed on: 12/14/2019