Shelby County Government
Grievance Form
Title II of the Americans with Disabilities Act

Instructions
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) :*

Address: *

Telephone Number: *

Alternate:

Email:*

Details of Complaint/Incident

Date/Time of Incident:*

Department/Facility/Location Involved:*

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…)*

Signature:*

If you have questions about this form, need an accommodation, or a different format, please contact the ADA Coordinator,
901.222.7705; John.Modzelewski@shelbycountytn.gov

Please allow us 15 business days to investigate and respond to your complaint