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2. Name
3. Email Address
5. Address
7. City
8. State
9. Zip Code
11. Phone Number (preferred)
13. Person(s) Refused Reasonable Accommodation (if other than the complainant):
15. Are you filling this complaint on your own behalf?*

    1. Yes*
    2. No

    *If you answered "yes" to this question, go to next section.
17. If not, please supply the name and relationship of the person for whom you are complaining: (Name and Relationship)
19. Please confirm that you have obtained the permission of the aggreved party if you are filing on behalf of that party:

    1. Yes
    2. No
21. Primary type of disability?*

    Please check specific disability:

    1. Mobility
    2. Cognitive/intellectual/development
    3. Learning
    4. Vision

    1. Mental/psychiatric
    2. Hearing
    3. Seizure

    1. HIV/Aids
    2. Diabetes
    3. Other or Not Listed
23. Describe your request for a reasonable accommodation:*
25. Specific location where we may need to take action (if applicable):
27. Are you able to use the public transportation system without this modification/accommodation?

    1. Yes
    2. No
29. Please explain:
31. Electric Signature*
32. Date*
    Date
34. You may submit this form to the address below by email, fax or mail to:
    Bev Bartlett
    Human Resource Officer
    City of Chadron
    234 Main St.
    PO Box 390
    Chadron, NE 69337
    Fax: (308) 432-0503
    personnel@chadron-nebraska.com
Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field