ADA Grievance Form – Sumner County, TN

The ADA Grievance Form is the form Sumner County, Tennessee, provides for a person to file a complaint under the Americans with Disabilities Act (ADA) about an alleged violation by a county department. It is printed under the heading "Americans with Disabilities Act (ADA) Grievance Form."

The form has three parts. Complaint Information records your name, address, optional email address and telephone numbers. Information on Alleged Violation asks for the date, a description of the violation and the remedy you request, then asks whether you have already tried to resolve the complaint through the department where the alleged discrimination occurred. If you answer "Yes," you give that department's name, a contact person, the contact's address and telephone, and the date you filed. A space for additional comments and a signature line close the form.

Sumner County's ADA notice names the ADA Coordinator, who is also the Sumner County Claims Manager, as the person who receives complaints. The county's page lists the form next to two companion documents: the Sumner County ADA Grievance Procedure and the Sumner County ADA Transition Plan. The form itself is the complaint only; it does not state a decision or a remedy.

Anyone who believes a Sumner County department has violated the Americans with Disabilities Act and wants to file a written complaint with the county can use this form. The complainant fills in the name, address and telephone numbers; an email address is marked optional.

Points the form and the county's ADA notice make clear:

• The form asks whether you have already tried to resolve the problem with the department where the alleged discrimination occurred. Answer Yes or No; the department details are completed only if the answer is Yes.
• If you need help completing the form, the form directs you to the Sumner County ADA Coordinator at 615.451.6023.
• The county's notice allows the complainant and/or his or her designee to appeal the written response, so a designee has a role after the response.

The form does not say who may sign for another person, so ask the ADA Coordinator if someone else will complete it on your behalf.

File the form when you want to report an alleged ADA violation by a Sumner County department. No filing deadline is printed on the form or on the county's ADA notice.

The county's notice sets the timeline that follows a complaint:

• Within 15 calendar days after the complaint is received, the ADA Coordinator or a designee meets with you to discuss the complaint and possible resolutions.
• Within 15 calendar days of that meeting, the county responds in writing, in an accessible format where appropriate, such as large print, Braille or audio tape.
• If the response does not resolve the issue, you or your designee may appeal to the County Mayor or another appropriate high-level official within 15 calendar days after receiving the response.
• The County Mayor or official then meets with you within 15 calendar days of receiving the appeal and gives a final written resolution within 15 calendar days after that meeting.

You can send the completed form to Sumner County Risk Management by mail or by email.

• By mail: Sumner County Risk Management, 355 N Belvedere Drive, Suite 303, Gallatin, TN 37066.
• By email: [email protected].
• By phone (questions and help): 615.451.6023, the number the form gives for the Sumner County ADA Coordinator if you need help completing it.

The form must be signed and dated. It can be completed electronically, or printed and handwritten in black ink. The form lists no fee and no attachments. The county's notice says complaints, appeals and the responses to them are kept by the county for at least three years. FillingPDF lets you fill out and download the PDF; submission follows the channels above.