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Resonable Modification/Accomodation Complaint Form

  1. Are you filling this complaint on your own behalf?*

    *If you answered "yes" to this question, go to next section.

  2. Please confirm that you have obtained the permission of the aggreved party if you are filing on behalf of that party:

  3. Primary type of disability?*

    Please check specific disability:

  4. Are you able to use the public transportation system without this modification/accommodation?

  5. 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

  6. Leave This Blank:

  7. This field is not part of the form submission.