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FRS Transportation -- ADA Complaint Form


SECTION I: CONTACT INFORMATION


Your Name:

Street Address:

City:

State:

Zip Code:

Phone (Home/Cell):

Phone (work):

Email:


Accessible Format Requirements

Large Print TDD Audio Other

SECTION II:


Yes No  (If you answered "yes" 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:



Yes No


SECTION III: ADA COMPLAINT DETAILS
Transportation Service Provider:


Date of Occurrence:


Time of Occurrence:


Name of Driver/Employee or Others Involved:


Vehicle ID Number or Route Name:


Direction of Travel:


Location of ADA Related Incident:


Mobility Aid Used (if any):


If above information is unknown, please provide other descriptive information to help identify the employee:


Description of ADA Incident:


SECTION IV: FOLLOW UP

Yes No


Phone Email Mail

If a phone call is preferred, which is the best day and time to reach you?



In Person Email Response Telephone Response Respones by U.S. Postal Mail



Please submit this form to:

ADA Coordinator
FRS Tranpsortation
313A Chillicothe Avenue
P.O. Box 502 (mailing address)
Hillsboro, OH   45133

Phone: (937)393-0585 ext 103
Fax: (937)393-0588
Email: melliott@frshighland.org or melody@frstransportation.org


NOTE: If information is needed in another language, then contact (937)393-0585


   
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