Complaint-Assistance Form

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Please correct the fields below:

Please correct the field(s) marked in red below:

Please fill out as much of this form as you can. If you need help, tell us, and we would be happy to provide it. If you do not know the answer to something, please leave it blank.

What is your name?

What is your name?

What is your email address?

What is your email address?

What is your address?

What is your address?

What is your phone number?

What is your phone number?ext.

May we leave a message at your phone number?

May we leave a message at your phone number?

The City’s ADA Coordinator helps to investigate and resolve disability access or discrimination issues for the City of Santa Maria’s Departments and their Contractors. Access issues usually fall into one of three categories. Please let us know which category best describes your issue:

Programmatic Access – Please check here if the access problem is programmatic – for example, you cannot get or maintain a City benefit or service because of a disability, or you asked for a reasonable modification of a policy, practice or procedure in order to obtain City benefits or services, but were denied one.

Communication Access – Please check here if the access problem involves communication – for example, you need an interpreter, materials in alternative formats, or other auxiliary aids and services in order to have equal access to information and communications for a City benefit, service or activity.

Architectural Access - Please check here if the access problem is architectural -- for example, a wheelchair ramp is needed, braille signage is missing, or accessible counters are too high for wheelchair users.

Which City Department or Contractor does this complaint involve?

Which City Department or Contractor does this complaint involve?

Please describe the problem you encountered or barrier to program access:

Please describe the problem you encountered or barrier to program access:

Please give us the date of the most recent problem:

Click on the icon to enter a date.

Please give us the location/address of the problem:

Please give us the location/address of the problem:

Is there a change in policy or procedure you wish to see that would be helpful in solving this problem?

Is there a change in policy or procedure you wish to see that would be helpful in solving this problem?

Do you know the name or position of any of the staff you encountered?

Do you know the name or position of any of the staff you encountered?

Your name (as a signature) indicating you signed this form:

Your name (as a signature) indicating you signed this form: If other, type text here.

Date of submittal:

Enter mm/dd/yyyy

This complaint will be sent to the City's Coordinator, who will conduct an investigation. We may assist in this investigation and will review the results.

You should receive a written response from the Department within a maximum of 30 days. If you do not, please contact us at:

ADA Coordinator
City of Santa Maria
110 E. Cook Street
Santa Maria, CA 93454

ADA@cityofsantamaria.org

To receive a copy of your submission, please fill out your email address below and submit.
Email Address

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