Americans with Disability Assistance Form

Phone Number (day):

Phone Number (evening):

Do you need a sign language interpreter?

Yes

The ADA Coordinator helps to investigate and resolve disability access problems and disability discrimination issues of the City of Neenah. Access issues usually fall into one of three categories. Please let us know which category best describes your issue:

Please Check All that Apply

Architectural Access - Please check this box if the access problem is architectural-for example, a wheelchair ramp is needed, accessible bathrooms are not available, or counters and phones are not at the correct height for wheelchair users.

Programmatic Access - Please check this box if the access problem is programmatic-for example, you cannot get or maintain a city benefit or service because of a disability or you asked for a reasonable modification of a policy or procedure in order to obtain City benefits or services, but were denied one.

Communication Access - Please check this box if the access problem involves communication-for example, you need an interpreter, materials in alternative formats, or other auxiliary aids and services in order to have equal access to information and communications for a City benefit, service or activity.

Name of city Funded Agency

Please describe the problem you encountered.

Please provide the location of the problem.

Is there a change in policy of procedure that you wish to see which would be helpful in solving this problem?

Yes

If you answered "Yes" to the above question please explain.

Do you know the name or position of any of the staff you have encountered to discuss this issue?

Yes

If you answered "Yes" to the above question, please list the staff members name and position if known.

Is there anyone else you are aware of who has experienced the same difficulty, or with whom you would like us to talk to in order to get more information?

Yes

If you answered "Yes" to the above question, please provide a name and phone number.

You may also contact the City of Neenah ADA Coordinator by mail at City of Neenah ADA Coordinator, c/o City Attorney, City Hall, 211 Walnut Street, Neenah, WI 54957 or email directly to attorney@ci.neenah.wi.us

The ADA Coordinator will conduct an investigation and attempt to resolve the request in a manner that is both satisfactory to you and consistent with applicable law. If you have provided your contact information, you should receive a written response from the City Attorney within a maximum of 30 days. If you do not, please contact us at 920-886-6106 or via email at attorney@ci.neenah.wi.us.