and STAR Transportation. . .

Steuben County Council on Aging • 317 S. Wayne St., Suite 1 B • Angola, IN 46703

C.O.A. Office (260)-665-8191  STAR Transportation (260)-665-9856

coa New Star Logo 19

Steuben County Council on Aging, Inc.

STAR Transportation

317 S. Wayne Street Suite 1-B

Angola, IN 46703

 

Title II of the Americans with Disabilities Act COMPLAINT FORM

Instructions: Please fill out this form completely, in black ink or type. Sign and return to the address on page 3.

Complainant:                                                                                        

Address:                                                                                                      

City:                                        State:                                                           Zip Code:                            

 

Telephone: Home:    _____________________ Business:    __________________________

 

Person Making the Complaint: (if other than the complainant):                                                                  

 

Address:                                                                                                          

City:                                        State:                                                        Zip Code:                          

Telephone: Home:    _____________________ Business:    __________________________

 

Department/Agency which you believe has discriminated:                                                                        

 

Name:                                                                                                            

Address:                                                                                                          

County:                                                                                                City:                                          

Telephone Number:                                                    

When did the event occur? Date: _________________________

_______________________________________________________________________________________________

Describe the event providing the name(s) where possible for the individuals who were involved (use space on page 3 if necessary):

 

 

 

Has the complaint been filed with the Indiana Department of Civil Rights or the Federal Department of Justice or any other Federal agency or court?  Yes    No

 

If yes: Agency or Court:                                                                               Contact Person:                                                                    

Address:                                                                                                          

City:                                        State:                                                        Zip Code:                            

Telephone Number:                                                                        

Date Filed:  ______________________

 

Do you intend to file with another agency or court?  Yes      No

Agency or Court:                                                                                                

Address:                                                                                                            

Telephone Number:                                                                              

Additional space for answers:

 

 

Signature: _____________________________________              Date:    ____________

Return to:

Steuben County Council on Aging, Inc. / STAR Transportation

Attn:  Executive Director

317 South Wayne Street,  Suite 1-B

Angola, IN 46703

Phone: 260—665-9408      FAX: 260-665-5247   Email:dkreais@steubencoa.org

Complaint Process  Title II of the Americans with Disabilities Act

 

Title II of the Americans with Disabilities Act (the “ADA”) protects qualified individuals with a disability from discrimination on the basis of that disability in the services, programs, or activities of Steuben County Council on Aging, Inc. and STAR Transportation. This notice is posted to inform the public of the provisions of Title II of the ADA and the requirements of the federal ADA regulations.

 

Complaint Procedure. Steuben County Council on Aging, Inc. and STAR Transportation does not discriminate against qualified individuals with a disability in its services, programs, or activities. Also, qualified individuals with a disability are not excluded from participation in or denied the benefits of the services, programs, or activities of the Civil Service Commission. If you have a complaint under Title II  of the ADA about the services, programs, or activities of the Civil Service Commission, you are encouraged to file your complaint with the ADA Coordinator for Steuben County Council on Aging, Inc. and STAR Transportation.

 

ADA Coordinator: Onda Dalton, Transportation Coordinator

Office Mail Address: 317 S. Wayne St. Suite 1-B Angola, IN 46703

Phone Number: 260-665-9856

FAX Number: 260-665-5247

E-Mail Address: odalton@steubencoa.org

 

Steuben County Council on Aging, Inc. and STAR Transportation complaint procedure is designed to informally resolve complaints of disability discrimination under Title II of the ADA. To file a complaint, please follow the steps of Steuben County Council on Aging, Inc. and STAR Transportation ADA Complaint procedure (listed on the next page).

 

IMPORTANT NOTES:

 

A.  Employment Complaints. Title I of the ADA—not Title II—addresses disability discrimination related to employment issues, including job application procedures, employment qualification standards, employment testing, hiring, advancement, discharge, employee compensation, job training, and other terms, conditions, and privileges of employment. If you have a complaint regarding any of these employment issues, you should not use this Title II ADA complaint procedure.

 

B.  No Waiver. This policy and complaint procedure is not a waiver of immunity of the Steuben County Council on Aging, Inc and STAR Transportation under the Constitution of the United States.

 

C.  Alternate Format. The information contained in this policy and complaint form are available in alternate format upon request.  Alternate format requests should be directed to the ADA Coordinator.

 

ADA Title II Complaint Procedure:

 

STEP 1. FILL OUT AND DELIVER YOUR COMPLAINT.

 

Fill out all of the information requested on the ADA Title II Complaint Form. Then mail or hand deliver the completed form to the ADA Coordinator for the Civil Service Commission. If you need a reasonable accommodation to communicate your complaint, such as an interpreter or an alternative format, list this on your complaint form so that the ADA Coordinator will be able to effectively communicate with you at your meeting.  You must file your complaint within 90 calendar days after the discriminatory action about which you are complaining.

 

STEP 2. MEET WITH THE ADA COORDINATOR.

 

Within 10 business days after you file your complaint, the ADA Coordinator will meet with you or contact you by telephone to discuss your complaint.

 

STEP 3. RESOLUTION OF YOUR COMPLAINT.

 

(A)  Complaint Resolved. If you and the ADA Coordinator jointly agree to a resolution of your complaint, the ADA Coordinator will put the joint agreement in writing and send it to you.  The agreement will generally contain the following items:

 

(1)  A description of your complaint.

(2)  A summary of the facts.

(3)  A description of the resolution agreed to.

(4)  The timeframe for resolving your complaint.

(5)  An assurance that the MDCS will comply with the specific terms of the agreement.

 

For this resolution to be effective, you must sign a copy of this agreement and return it to the ADA Coordinator in the time specified.

 

(B)  Complaint Not Resolved. If you and the ADA Coordinator cannot resolve your  complaint, the ADA Coordinator will send you a notice of that fact. The notice will generally include the following:

(1)  A description of your complaint.

(2)  A summary of any resolution proposed.

(3)  A statement addressing the issues that could not be resolved.

 

If your complaint is not resolved, you may request a further review of your complaint by the Indiana Department of Civil Rights. You should file a request with the Department of Civil Rights within 10 business days after you receive your notice of non-resolution from the Civil Service ADA Coordinator. Send a copy of your original complaint and the Civil Service non-resolution notice to the Department of Civil Rights.