Appendix A: ADA Grievance Procedure Form
NOTE: Appendix A is available in PDF, click HERE
Grievance Procedure Form
American’s with Disabilities Act
McHenry County, Illinois
   This form is to be used by any person who wishes to file a grievance regarding alleged discrimination under Section 504 Title II of the Rehabilitation Act of 1973 of the Civil Rights Act of 1964.
   After completing this form, please make yourself a copy, and mail it or drop it off at the Office of the County Administrator, McHenry County, McHenry County Government Center, 2200 N. Seminary Avenue, Woodstock, Illinois 60098.
   Appropriate responses and resolutions will be processed within sixty (60) days after receipt of this form in the Office of the County Administrator, and written replies sent to the address which appears below.
   Your Name: _______________________________________________________________
   Your Address: _____________________________________________________________
   Your City, State, Zip: _______________________________________________________
   Your Phone Number: (____)__________________________________________________
   State the nature of the complaint. including the particular McHenry County Office, service, program, or building involved: (Please be as specific as possible, including dates, names, and circumstances of the occurrence.)
(Use the back of this form or another sheet of paper, as needed)
________________________________________________            ______________________________
Your Signature Must Appear On This Line               Date
(Ord. O-9709-12-81, passed 9-16-1997)