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ADA Complaint Form

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ADA Complaint FormHCS2022-12-14T09:01:17-05:00

ADA Complaint Form

The Americans with Disabilities Act of 1990 (ADA) requires that individuals with disabilities receive the same level of service as non-disabled individuals. Section 504 prohibits discrimination on the basis of disability in any program or activity receiving Federal financial assistance. Please provide the following information necessary in order to process your complaint. Should you require any assistance in completing this form, please let us know. You may also mail this form to us: Corporate Compliance Officer VNA at HCS P.O. Box 564 Keene, NH 03431

Name
Address
Accessible Format Requirements:

Are you filling this complaint on your own behalf?

If NO:

Please supply the name of the person for whom you are complaining and your relationship to them:
Name
Have you obtained permission to file on behalf of the complainant?

MM slash DD slash YYYY
Have you previously filed an ADA complaint with this agency?
Have you previously filed this complaint with any other federal, state, or local agency, or with a federal or state court?
If YES, please check each agency the complaint was filed with:

Please provide the name of a contact person at the agency/court where the complaint was also filed:
Agency/Court Contact Name
Agency/Court Contact Address

Max. file size: 50 MB.
MM slash DD slash YYYY

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