ADA and Section 504 Complaint Form

Name of Complainant *

First and Last Name

Complainant Contact Information

Email Address *

Day Phone Number *

Evening Phone Number

Street Address

City

State

Zip Code

What is the best way to communicate with you? *

Please let us know if you want written communications in a specific format (e.g., large print, Braille, electronic documents) or require communications by video phone or TTY.

Incident Details

Date of Incident *

Month

Day

Year

Location of Incident *

Please specify where in, or near, the Museum this incident took place. For example: an exhibition (include title or topic), a restroom, etc.

Please provide a description of what happened and who was involved *

Explain what steps, if any, you or the Museum has already taken to resolve this matter

Describe how you would like to see this matter resolved *

Describe any other corrective actions you would like to see

Alternate Contact Information

If the person discriminated against is not the complainant, please also provide contact information for this person.

Name of Person Discriminated Against

First and Last Name

Phone Number

Street Address

City

State

Zip Code

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ADA and Section 504 Complaint Form

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Complainant Contact Information

Incident Details

Alternate Contact Information

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