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Kim P. Nuckles
State ADA Coordinator

Building 1, Room E-119
1900 Kanawha Boulevard, East
Charleston, WV 25305

304-558-4331 x 57004 (Voice)
304-558-2999 (Fax)

adacoordinator@wv.gov

 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:
Select a date from the calendar.
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

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