Form Center • Murfreesboro, TN • CivicEngage

Introduction

Americans with Disabilities Act (ADA)
The Americans with Disabilities Act (ADA) (Title I) prohibits discrimination in all employment practices, including job application procedures, hiring, firing, advancement, compensation, training, and other terms, conditions, and privileges of employment. It applies to recruitment, advertising, tenure, layoff, leave, fringe benefits, and all other employment-related activities. If you believe you have been the target of discrimination on the basis of disability by the City, a City official, employee, or contractor, or a City subrecipient of federal funds, you may file a complaint by completing this form and submitting it to:
Pam Russell
ADA Co-Coordinator and Human Resources Director
111 West Vine Street
Murfreesboro, TN 37130
Tel: (615) 848-2553
Fax: (615) 904-6506
Email Pam Russell
Additional Information
Alternatively, complaints may be submitted to the City Manager. If you need assistance completing this form, please contact the City’s Human Resources Department at (615) 848-2553. Copies of the City’s ADA complaint procedures are available online.

The City’s complaint procedure is an administrative process that does not provide for compensatory or punitive damages. This process is not exclusive, as you may also choose to file a complaint with a state or federal agency or the courts. Other agencies will have time limits for filing complaints. Generally, federal agencies require Title I complaints to be filed within 180 days of the date of the alleged discrimination.
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Section A

Section A: Complainant’s Contact Information
First Name*
Last Name*
Address1*
Address2
City*
State*
Zip*
Day Time Telephone*
Email*
Cell Phone
Work Phone
Are you a current City employee or a job applicant?*
1. Current Employee
1. Job Applicant
Position held or sought*
Department*
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Section B

Section B: Please provide the following information about the alleged discrimination.
I consider myself to be an individual with a diability for purposes of this complaint because:*
1. I have physical or mental impairment that substantially limits one or more major life activities;
2. I have record of having such an impairment in the past; or
3. I am regarded as having such an impairment.
Briefly describe the impairment that you have, that you have a record of, or that you are regarded as having. *
Has the City (e.g., your supervisor or department head, or the City Human Resources Department) previously been made aware of your disability status?*
1. Yes
1. No
If yes, when?
If yes, when?
How was the City made aware of your disability status, i.e., who did you tell and how did you tell them?
If you notified the City in writing, please attach a copy of the notification(s).
Have you ever requested an accommodation by the City for a current or past disability?*
1. Yes
1. No
If yes, when?
If yes, when?
What was the date and nature of the accommodation request?
If any request was written, attach a copy of the request(s).
Please describe the incident or action(s) giving rise to the complaint, e.g., what occurred, who was involved, why you believe it occurred, and how you were discriminated against. Please provide as much detail as possible.*
What do you suggest the City do to resolve this issue or problem? Please be specific and recommend alternative solutions.
Complainant's Signature*
The City will not accept unsigned complaints.
Date*
Date

Leave This Blank:

1. Receive an email copy of this form.
Email address

This field is not part of the form submission.
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ADA Complaint - City Employee or Job Applicant (FORM 2008C, Revised 8/14/2017)

Steps

Introduction

Section A

Section B

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