Pinellas County ADA Grievance Form

*Pinellas County ADA Grievance Form** (*Americans with Disabilities Act) View ADA Grievance Procedure
Your Name
Your Address
City
State
Zip Code
Phone Number
Cell Phone Number
*e-Mail Address
Date the aggrieved action occurred or was observed
Name and location of the County program or service involved which is the subject of the Complaint
Name of the County employee representative with whom you made contact regarding the subject of this grievance
Describe why you believe you are the victim of discrimination on the basis of disability in the delivery of Pinellas County programs and services
*your e-mail address is required to submit form Note: Under Florida law, e-mail addresses are public records. If you do not want your e-mail address released to a public-records request, do not send electronic mail to this entity. Instead, contact this office by phone at (727) 464-4880 or in writing to Pinellas County ADA Coordinator, 400 S. Ft. Harrison Ave., Clearwater, Florida 33756.