State ADA Coordinator

Building 6, Room 436
Charleston, WV 25305

304-558-3950 ext.57292 (Voice)
304-558-1852 (Fax)

ADA > Complaint Form

Complaint Form

Person Filing Complaint:
All fields marked with * are required fields.

Name: *

Address: *

City: *

State: *

Zip Code: *

Telephone Number: *

Fax Number:

E-mail Address:

Date of alleged disability-related discrimination:

Location of alleged disability-related discrimination:

Please provide a detailed description of the alleged disability-related discrimination:

Please provide the names and/or positions of any state personnel involved:

Please state what action you believe should be taken to resolve this complaint:

Attachments