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ADA Complaint Form
The American's with Disabilities Act (ADA) protects individuals with disabilities in relation to any
services, programs, activities, and employment. If you believe you have been subjected to
discrimination in transit services or employment under the ADA, you may file a complaint with this
form. Please contact GO Transit by calling (920) 232-5340 with any additional questions.
Please send completed form to:
GO Transit — Attn: ADA Complaints
926 Dempsey Trail
Oshkosh, WI 54902
transit@ci.oshkosh.wi.us (email)
920-232-5343 (fax)
Please print clearly:
Name:
Address:
City, State, Zip:
Phone #
Person discriminated against (if different):
Address (if different):
City, State, Zip (if different):
Email:
Please indicate why you believe the alleged discrimination occurred (circle all that apply):
Mobility Impairment
Vision Impairment
Cognitive Impairment
Hearing Impairment
Other:
Date of the alleged discrimination:
Where did the alleged discrimination take place?
Learning Disability
Speech Impairment
Mental Health Issue
Medical Issues
Please describe alleged incident. Provide the names of all Go Transit employees involved if available.
Explain what happened and whom you believe was responsible. Please use the back of this form if
additional space is required.
GO Transit ADA Complaint Form
Please list any and all witnesses' names and phone numbers:
Name:
Name:
Name:
Name:
Contact Number:
Contact Number:
Contact Number:
Contact Number:
What type of action would you like to see taken?
Please attach any documents you have which support the allegation. Date and sign this form and sent
it to the ADA Coordinator at the address listed on page 1 of this form.
I affirm that I have read the above charge and that it is true to the best of my knowledge, information
and belief:
Complainant's Printed Name:
Complainant's Signature
For CO Transit office use only:
Date received by CO Transit:
Received by:
GO Transit ADA Complaint Form
Date