Americans with Disabilities Act (ADA) Grievance Form

Leave This Blank:

City of Burnsville
Title II of the Americans with Disabilities Act and Section 504 of the Rehabilitation Act of 1973 Discrimination Complaint Form

Instructions: Please fill out this form completely.

Government, or organization, or institution which you believe has discriminated:
NOTICE OF RIGHTS
In accordance with the Minnesota Government Data Practices Act, the City of Burnsville is required to inform you of your rights as they pertain to the private information collected from you. Your personal information we collect from you is private. Access to this information is available only to you and the agency collecting the information and other statutorily authorized agencies, unless you or a court authorizes its release.

The Minnesota Government Data Practices Act requires that you be informed that the following information, which you are asked to provide, is considered private.

The purpose and intended use of the requested information is:
To assist City staff and designees to evaluate and respond to accessibility concerns.

Authorized persons or agencies with whom this information may be shared include:
City of Burnsville officials, staff or designee

Furnishing the above information is voluntary, but refusal to supply the requested information will mean:
City staff may be unable to respond to or evaluate your request.

 
* indicates required fields.