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2. Date of Notification*
   Date of Notification
4. First Name*
5. Last Name*
7. Mailing Address*
9. City*
10. State*
11. Zip*
13. Phone Number*
14. Email*
16. Description of accessibility issue*

    Describe in detail the accessibility issue(s), including specific location(s) of web content or document(s).

18. Additional Documentation (optional)

    Upload any additional documentation that would support your grievance.

20. Electronic signature*

    By checking the "I agree" box below, you agree and acknowledge that 1) your notification will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
22. Notification Response Timeline

    Within 15 calendar days after receipt of the notification, we will contact the person initiating the notification to discuss the problem and the possible resolutions. Within 30 calendar days of the meeting, we will respond in a format accessible to the complainant. The response will explain the position of the County and offer options for a resolution. If the response by the County does not satisfactorily resolve the issue, the complainant or their designee may submit a grievance to the Colorado Civil Rights Division or the U.S. Department of Justice.

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24. 1. Receive an email copy of this form.
25. Email address

    This field is not part of the form submission.

26. Submit

* indicates a required field