Rider Complaint Form

The Federal Transit Administration (FTA) Office of Civil Rights is responsible for civil rights compliance and monitoring of public transportation, which includes ensuring that providers properly implement Title II of the Americans with Disabilities Act of 1990 (the ADA), the Department of Transportation (DOT) ADA regulations, and Section 504 of the Rehabilitation Act of 1973.

In the FTA complaint investigation process, we analyze the complainant's allegations for possible ADA deficiencies by the transit provider. If deficiencies are identified they are presented to the transit provider and assistance is offered to correct the inadequacies within a predetermined timeframe. FTA also may refer the matter to the U.S. Department of Justice for enforcement.

Section I

Name:_____________________________________________

Address:___________________________________________

              ___________________________________________

Telephone Numbers:

(Home)_________________________

(Work)__________________________

Electronic Mail Address:__________________________________

Accessible Format Requirements?

Large Print _______ Audio tape _____

TDD ___________ Other________________________________________

Are you filing this complaint on your own behalf?

Yes ____ No ____

[If you answered "yes" to this question, go to Section III.]

If not, please supply the name and relationship of the person for whom you are complaining: ______________________________________________________________________

Please explain why you have filed for a third party. _______________________________ ______________________________________________________________________

Please confirm that you have obtained the permission of the aggrieved party if you are filing
on behalf of a third party.

Yes ____ No ____

Have you previously filed an ADA complaint with FTA? Yes____ No___

If yes, what was your FTA Complaint Number? ____________________

[Note: This information is needed for administrative purposes; we will assign the same complaint
number to the new complaint.]

Have you filed this complaint with any of the following agencies?

Transit Provider _____ Department of Transportation ____

Department of Justice_____ Equal Employment Opportunity Commission _____

Other _____________________________________________

Have you filed a lawsuit regarding this complaint? Yes_____ No____

If yes, please provide a copy of the complaint form.

[Note: This above information is helpful for administrative tracking purposes.]

Name of public transit provider complaint is against:

_____________________________________________________________________

Contact person: _________________________ Title: __________________________

Telephone number: _____________________________________________________

On separate sheets, please describe your complaint. You should include
specific details such as names, dates, times, route numbers, witnesses,
and any other information that would assist us in our investigation of
your allegations. Please also provide any other documentation that is
relevant to this complaint.

May we release a copy of your complaint to the transit provider?

Yes ____ No ____

May we release your identity to the transit provider?

Yes ____ No ____

Please sign here: _____________________________________________

Date: ______________

[Note - We cannot accept your complaint without a signature.]