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U:\Clerk Info\ADA COMPLIANCE\ADA Title II Grievance,Complaints Forms.docx A-1 Appendix A ADA Grievance Procedure The City’s Grievance Procedure is established to meet the requirements of the Americans with Disabilities Act of 1990 It may be used by anyone who wishes to file a complaint alleging discrimination on the basis of disability in the provision of services, activities, programs, or benefits by the City of Jerome (COJ). COJ’s Personnel Policy governs employment-related complaints of disability discrimination. The complaint should be in writing and contain the following information about the alleged discrimination: Contact – provide the name, address, telephone number, and signature of complainant/grievant or their designee Description – provide facts and circumstances surrounding the claimed discrimination, including date of allegations, and basis of complaint References - any names of persons, if known, that the investigator could contact for additional information to support or clarify the allegations Resolution – what corrective action is being sought by the complainant/grievant Alternative means of filing complaints include attending City Council meetings held on the 2nd and 4th Tuesdays of every month at 5:30 PM. The complaint should be submitted by the complainant/grievant and/or their designee as soon as possible but no later than 180 calendar days after the alleged violation to the contacts in Appendix B – ADA Program Contacts. Within 10 calendar days after receipt of the complaint, the COJ staff will discuss the complaint with the complainant/grievant and identify possible resolutions. Within 60 calendar days of receipt, a member of the COJ staff will investigate to determine the validity of the alleged violation. The final resolution of the complaint will be shared with the complainant/grievant. All written complaints received by the ADA Program Contacts, appeals to the COJ, and responses from the COJ, will be retained by the COJ for at least three years. ---PAGE BREAK--- U:\Clerk Info\ADA COMPLIANCE\ADA Title II Grievance,Complaints Forms.docx A-2 City of Jerome, Idaho Americans with Disabilities Act (ADA) Complaint / Grievance Form Purpose: this form is to be used to file a complaint / grievance alleging discrimination on the basis of disability in the provision of services, activities, or benefits provided by the City of Jerome, Idaho Instructions: If you are the person we should contact, please submit your information and your preferred method of contact. If you are completing this form for another individual, please submit their contact information and their preferred method of contact If you would like to include additional information, please provide that information and attach it to this form. Contact Information of Complainant / Grievant Name: Complete street address and ZIP code: Telephone number: Email address: Preferred method of contact: Contact Information of Representative for the Complainant / Grievant (complete if applicable) Name: Complete street address and ZIP code: Telephone number: Email address: Preferred method of contact: COMPLAINT OR GRIEVANCE Please provide a complete description of the specific complaint / grievance: Please specify any location(s) related to the complaint / grievance (if applicable): Please state what you think should be done to resolve the complaint / grievance: Note: If you would like to include additional information, please attach it to this form. Signature: SIGN ---PAGE BREAK--- U:\Clerk Info\ADA COMPLIANCE\ADA Title II Grievance,Complaints Forms.docx A-3 Please submit this form not more than 180 days from the date of the alleged discrimination. Bernadette Gomes, City Clerk/ADA Coordinator Jerome City Hall 152 E Avenue A Jerome ID 83338 Ph. [PHONE REDACTED] x105 Fax [PHONE REDACTED] [EMAIL REDACTED] The City’s ADA Coordinator or her designee will contact you to discuss your request within fifteen (15) days of the receipt of this form and any accompanying information. The City’s ADA Complaint / Grievance Procedure and its ADA Transition Plan are available on the City of Jerome’s website, www.cityofjerome.org The City of Jerome does not discriminate on the basis of disability in its employment practices or in the admission to, access to, or operations of its services, programs, or activities. Bernadette Gomes, ADA Coordinator, has been designated to coordinate compliance with the ADA non-discrimination requirements.