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 [TDD]

Fax: (808) 587-6306

E-mail: mike_medeiros@exec.state.hi.us