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City of Anaheim Grievance Form Instructions: Please fill out this form completely in black ink or type. Sign and return to Department Liaison or ADA/Title VI Coordinator Office, 955 S. Melrose St., Anaheim, CA 92805. This form is optional and provided for your convenience. Grievant Name: Address: Email Address: Telephone: Work: Cell: If a legally authorized representative is filing the grievance on your behalf, his/her name, address and telephone number must also be included: Name: Address: Email Address: Telephone: Work: Cell: Please check off why you believe the discrimination occurred: Race or Color Age National Origin Sex Disability Other Date of Incident: Time of Incident: Location or address of incident: Describe your grievance: What type of corrective action would you like to see taken? If the incident(s) involved a City of Anaheim employee(s), his/her name(s) please included: The name(s) and contact information of witnesses: If your grievance is being filed on behalf of another person or a group of people, all of the grievant(s) should be described or identified by name, if possible. Grievant: Date: Legally Authorized Representative: Date: