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3. COUNTY OF HUMBOLDT DISCRIMINATION ON THE BASIS OF DISABILITY COMPLAINT FORM

   This form should be used by all persons who wish to file a complaint against the County or its officers or employees because of discrimination on the basis of disability. The completed form should be filed with either the County Personnel Director, the County Administrative Officer or the County official directly responsible for the service, program or activity, whomever is most appropriate under the circumstances. Investigation of all complaints shall be handled in an expedited fashion.

5. Further questions regarding the Grievance Procedure Under the ADA or the County's Policy on Non-Discrimination on the Basis of Disability may be directed to Karen Clower at:

7. Physical Address
   County of Humboldt - ADA 825 5th Street, Room 112 Eureka, CA 95501
8. Email

   ADA@co.humboldt.ca.us

9. Office Phone

   707-445-7266

10. Toll-Free Phone

    (844) 365-0352

14. First Name
15. Last Name
17. Address1
19. City
20. State
21. Zip
23. Telephone
24. Email Address
26. Check if applicable:

    1. Current County Employee
    2. Applicant for County Job
30. 1. Clearly describe your complaint or difficulty in detail:
32. 2. Time, date, and location of the incident(s):
34. 3. Names of any County employees who are involved or other witnesses (if known):
36. 4. Has this complaint been discussed with the responsible county employee or department?

    1. Yes
    2. No
38. 5. What remedy or corrective action is requested?
40. I certify that all statements or allegations made herein are true to the best of my knowledge*
    By typing your name and date in this field and clicking the 'submit' button, you certify that all statements or allegations made herein are true to the best of your knowledge.
Leave This Blank:


44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

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