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2. Complete this form to report a concern to the Americans with Disabilities Act (ADA) Coordinator at Placer County.
   
   Upon request, reasonable accommodation will be provided in completing this form, or copies of the form will be provided in alternative formats.
4. Date*
   Date
6. First and Last Name*
8. Phone Number*
9. Email*
11. Street Address
13. City
14. State
15. Zip
17. Country
19. Report a concern related to:*
    -- Select One --ConstructionBuildings and FacilitiesJobs and EmploymentRoads and SidewalksTransit and TransportationWebsite and TechnologyOther
21. Please provide a complete description of the specific complaint or grievance:*
23. Please specify any location(s) related to the complaint or grievance (if applicable):
25. Please state what you think should be done to resolve the complaint or grievance: *
Leave This Blank:


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

    This field is not part of the form submission.

29. Submit

* indicates a required field