Accessibility Complaint Form

ACCESSIBILITY COMPLAINT FORM

The Los Angeles County Public Works (Public Works) is committed to ensuring that no person shall be discriminated on the basis of disability in the admission and access to its services, programs, or activities. To report an issue regarding accessibility, please complete this form.

Person Completing Form (select one):

Complaintant Authorized Representative *

* An authorized representative is a person with authority to act in the best interest of the participant.

Occurrence Date

May 2023
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Customer Information:

First Name

Last Name

Authorized Representative (if applicable):

First Name

Last Name

Address

City

State

Zip Code

Telephone Number

E-mail Address

Accessibility Complaint Information:

I believe the discrimination I experienced was based on (check all that apply):

Physical Access
Interpreter/Assistive Listening
Accommodation Request
Service Animal
Retaliation
Denial of Services/Refusal to Admit
Other or Don't Know

Please provide additional information if selected "other".

Name of Public Works program or location where service was received or denied, which is the subject of this complaint:

Please describe how Public Works has not complied with delivering its programs and services. Provide sufficient details to support your complaint.

	S	M	T	W	T	F	S
18	30	1	2	3	4	5	6
19	7	8	9	10	11	12	13
20	14	15	16	17	18	19	20
21	21	22	23	24	25	26	27
22	28	29	30	31	1	2	3
23	4	5	6	7	8	9	10

	S	M	T	W	T	F	S
18	30	1	2	3	4	5	6
19	7	8	9	10	11	12	13
20	14	15	16	17	18	19	20
21	21	22	23	24	25	26	27
22	28	29	30	31	1	2	3
23	4	5	6	7	8	9	10

	S	M	T	W	T	F	S
18	30	1	2	3	4	5	6
19	7	8	9	10	11	12	13
20	14	15	16	17	18	19	20
21	21	22	23	24	25	26	27
22	28	29	30	31	1	2	3
23	4	5	6	7	8	9	10