Oklahoma Department of Transportation Project …
OKLAHOMA DEPARTMENT OF TRANSPORTATION 200 N.E. 21st Street Oklahoma City, Oklahoma 73105-3204 (405) 522-4085
ADA Complaint Form
1. ________________________________________________________________
Last Name Middle Initial First Name
________________________________________________________________
Street Address City State Zip Code
________________________________ ______________________________
Telephone Number (including area code) Best time to call this number
________________________________ ______________________________
2nd Telephone Number (including area code) Best time to call this number
________________________________________________________________
e-mail address
2. Please Provide a complete description of the specific issue(s) you believe inconsistent with Title II of the Americans with Disabilities Act (use additional pages as necessary and provide documentation supporting the allegation)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
3. Please provide a specific location(s) of the ADA issues prompting this complaint
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
________________________________________________________________
4. Date when the ADA non-compliance occurred / was noted
_____________________________________________________________________________
ODOT Form ADA -1-08 page 1 0f 2
5. Please state as specifically as possible what you think should be done to resolve the complaint
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_________________________________ ____________________________
Signature Date
Mail Completed Complaint Form to:
Oklahoma Department of Transportation
200 N.E. 21st Street
Oklahoma City, Oklahoma 73105-3204
Attn: Title II Coordinator
For Agency Use Only:
________________________________ _______________________________
Date Complaint was received Date Complaint investigated
_________________________________________________________________
Results of Investigation (attach supporting documentation or photographs)
_________________________________________________________________
_________________________________________________________________
________________________________
Date Complainant Contacted Method of Contact ( Phone
( Letter
( Personal Visit
Complaint Resolved? ( Yes
( No (forward to Civil Rights Division for review)
ODOT Form ADA -1-08 page 2 0f 2
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