Form Center

2. Name*
4. Address1*
6. City*
7. State*
8. Zip*
10. Are you filing this inquiry: (Check all that apply)*

    1. A. On behalf of yourself as a person with a disability?
    2. B. As a person associated with another who has a disability?

    1. C. As an interested person?
    2. D. On behalf of a family member or ward who has a disability? PLEASE describe your relationship:
12. Please Describe:
14. ABOUT YOUR INQUIRY: Name of program, service, activity, park or facility involved:*
16. Location / Date & Time of occurrence you believe was discriminatory or unfair:*
18. WHAT HAPPENED? Please describe in your own words the action(s) by an employee(s), the rules or policy, the service(se) or the condition of a park, area, facility or structure which you feel is discriminatory or unfair. It is not necessary to refer to laws, regulations, ordinances, or policies in your description.*
20. HOW CAN THE PROBLEM BE CORRECTED? Please describe the actions, which you feel need to be taken to address the problem.
22. IS THERE A DEADLINE? Must this problem be addressed before a program begins or an event occurs? Please identify any date, which you feel is important to the problem.
24. PLANNING A CONFERENCE: The City will contact you to schedule a meeting to discuss your complaint. The meeting will occur within fifteen (15) calendar days from the date your inquiry is received. Do you need an accommodation during the conference? If yes, please describe:
26. When are you most available? (Check two)*
    -- Select One --M-F 9:00-11:00 a.m.M-F 2:00-5:00 p.m.M-F after 5:00 p.m.Sat 9:00 a.m. - NoonOther
28. Signature*
29. Email
31. SUBMITTING THIS FORM:

    Thank you for completing this form.  We will contact you soon.  

    For assistance with this form, or for information about program accessibility, please call (314) 962-4800 Voic or please use Relay Missouri 1-800-735-2966 TDD.  

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34. Email address

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