ADA Complaint Form

Members of the public who believe they have received unequal treatment or discrimination or that a Department of Environmental Quality facility, program, service, or activity was not accessible to you because of a disability, you may file a complaint using the form below within 180 days from the date of the alleged discrimination.

DEQ employees should submit complaints to DEQ’s Human Resource Office, the Equal Employment Opportunity Commission, or the Human Rights Commission.

Para ver esta información en español, envíe un correo electrónico accessibility@deq.idaho.gov.

For further assistance, contact DEQ’s nondiscrimination coordinator:

Idaho Department of Environmental Quality
ATTN: Nondiscrimination Coordinator
1410 N. Hilton Street
Boise, ID 83706
accessibility@deq.idaho.gov
(208) 373-0271

ADA Complaint Form

1. Complainant's Contact Information

First Name Last Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

2. Person discriminated against (if other than Complainant)

First Name Last Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

3. Date of Incident

Location of Incident

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

4. List the Idaho Department of Environmental Quality employee(s) or representative(s) involved in the incident (name, office or department and position, if known):

5. What was the discrimination based on: (Check all that apply)

Race/ Color

National Origin

Low Income

Sex

Disability

Limited English Proficiency

6. Describe how you were discriminated against. What happened and who was responsible?

8. Witness Contact Information

First Name Last Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

I certify that to the best of my knowledge and belief that the statements and information on this form are true, accurate, and complete.(Required)

Date