Grievance Complaint Form

Attachment I-3

STATE OF HAWAII - DEPARTMENT OF TRANSPORTATION

AMERICANS WITH DISABILITIES ACT – TITLE II

GRIEVANCE FORM

1. Complainant

Name:                                                                                                                          

Address:                                                                                                                      

Phone:                                                                                                                         

2. Designee (if applicable)

Name:                                                                                                                          

Address:                                                                                                                      

Phone:                                                                                                                         

3. Date (s) Incident Occurred:                                                                                     

4. Nature of Complaint

(Please include date, time, place, people involved, witnesses and circumstances)

5.         Request for Special Accommodations (Describe)                                         

Mail To:                 State of Hawaii - Department of Transportation

                              Office of Civil Rights, Room 112

                              869 Punchbowl Street

                              Honolulu, Hawaii 96813

                              Phone (808) 587-7584 [Voice], 587-2210 [TTY]

                              Fax: (808) 587-2025

                              E-mail: Benjamin.gorospe@hawaii.gov