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Shelby County Government
Title II of the Americans with Disabilities Act
Please fill out this form completely, sign and return to:
John C. Modzelewski, P.E.,CFM
Shelby County Government ADA Coordinator
6449 Haley Rd.
Memphis, TN 38134
This information will be held in confidence unless instructed otherwise by you. Please note that this grievance procedure is for facilities, services, and programs owned and/or operated by Shelby County Government.
Name (Complainant) :
Details of Complaint/Incident
Date/Time of Incident:
Reason for Grievance/Complaint, or why you feel you have been discriminated against. Please be specific and provide as much information as possible (i.e. location, date, time, names, etc…)
If you have questions about this form, need an accommodation, or a different format, please contact the ADA Coordinator,
Please allow us 15 business days to investigate and respond to your complaint
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