ADA Title II Grievance and Complaint Form (Online Submission Form)

The County of Orange ensures that no person or groups of persons shall, on the grounds of race, color, sex, religion, national origin, age, disability, retaliation, or genetic information, be excluded from participation in, be denied the benefits of, or be otherwise subjected to discrimination under any and all County programs, services, or activities administered.

Instructions: You may submit an online Grievance and Complaint Form by completing the fields below and clicking the "submit form" or submit a signed response to the address listed below by email, fax, mail, or in person within 60 days of the alleged incident. If you need an accommodation to complete or submit this form, please contact the respective Department ADA Coordinator.

1. Grievant Information:

2. Designated Person to Contact (If Other Than the Grievant):

3. Alleged Accessibility Issue with County of Orange Program, Service, or Activity:

4. Describe The Incident/Complaint with Enough Detail so the Nature of the Grievance Can Be Understood:

5. Have Attempts Been Made to Resolve the Complaint Through a County Department? If Yes, Please Describe the Efforts That Have Been Made:

6. If the Alleged Incident Involved County Employee(s), Please List Name(s):

7. Name and Contact Information of Witness(es), If Applicable:

8. Proposed Solution for Your Grievance:

By submission of this form, I certify that the statements contained in it are true and correct to the best of my knowledge and belief.