[DC GOVERNMENT] Request_Assistance_or_File_a

Request Assistance or File a Complaint

Please fill out as much of this form as you can. If you need help, tell us, and we will be happy to provide it. If you don't know the answer to something, please leave it blank.

(*) Required Fields

Phone Number

Is this TTY

Yes

Fax

Are you a Veteran?

Yes

How do you prefer to be contacted (i.e., phone, email, etc.)

Access Issue Category

Architectural Access - Please check here if the access issue is about a building -- for example, a wheelchair ramp is needed, accessible bathrooms are not available, or counters and phones are not at the correct height for wheelchair users.

Programmatic Access - Please check here if the access problem is about a service -- for example, you cannot get or maintain a city benefit or service because of a disability, or you asked for a reasonable modification of a policy, practice or procedure in order to obtain District of Columbia benefits or services, but were denied one.

Communication Access - Please check here if the access issue involves communication - for example,you need an interpreter, materials in alternative formats, or other auxiliary aids and services in order to have equal access to information and communications for a District of Columbia benefit, service or activity.

Employment - Please check here if this is an employment issue. For example, being denied a reasonable accommodation.

Which District agency does this complaint involve?

Please describe the issue you encountered:

Please give us the date of the most recent issue:

Please give us the location of the issue:

Is there a change in policy or procedure you wish to see that would be helpful in resolving this issue?

Names and Positions of Staff Encountered (if known).

Does anyone else have information about this situation or issue that you think we should contact?

Phone Number

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