Accommodation and Disability Discrimination Complaint Form

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Complaints will be reviewed by Olathe’s ADA Coordinator, Tim Danneberg, and may be shared with Olathe’s Persons with Disabilities Advisory Board. Claims may be redirected to other agencies such as HUD, EEOC, and/or the Kansas Human Rights Commission for investigation, as appropriate.

The complaint form below is provided in accordance with the American with Disabilities Act (ADA) and must be completed by or on behalf of a person who has been denied a reasonable accommodation due to a qualifying disability.

Please complete the form in its entirety, as it constitutes your formal complaint against the City of Olathe. Fields marked with an asterisk (*) are required. Upon request, alternative means of filing complaints, such as personal interviews or a recording of the complaint, will be made available for person with disabilities. For questions or to request alternative means of filing a complaint, contact the ADA Coordinator, Tim Danneberg (913-971-8609 or tdanneberg@OlatheKS.org).

Please correct the fields below:

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

Complainant's Full Name and Contact Information

*

Complainant's Full Name and Contact Information

First Name

Middle Name

Last Name

Suffix

Street Address/PO Box

City

State

Zip Code

Phoneext.

E-Mail

Complainant's Primary Disability

*

Complainant's Primary Disability

Learning/Cognitive Disability

Deafness or Hearing Impairment

Motor Disability

Visual Impairment

Multiple Disabilities

City Department and/or Program which Complainant believes has discriminated

*

City Department and/or Program which Complainant believes has discriminated

Department and/or Program Names

Location

Department and/or Program Phoneext.

Discrimination Occurred

*

Discrimination Occurred

Date

Time of Day

Describe the discriminatory incident

*

Describe the discriminatory incident

Have efforts been made to resolve this complaint?

*

Have efforts been made to resolve this complaint?

Yes

No

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

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