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Michael Hurt Chief Diversity & Inclusion Officer

mhurt@cityblm.org

(309) 434-2468

ADA Grievance Complaint Form

The information collected in this form will be used to file a formal ADA Grievance Complaint. During the investigation of the complaint, you may be contacted to further discuss the complaint and/or possible solution. If you do not wish to participate in a formal grievance procedure, please contact the City's ADA Coordinator, Michael Hurt.

Phone: (309) 434-2468
Email: mhurt@cityblm.org

Full Name

Full Address

Classification of Accessibility /Concern/Inquiry (Choose all that apply)

Your grievance complaint will be submitted to the ADA Coordinator, who may contact you for additional information. You will receive a written response to your complaint within 30 days. If another form of response is required, or you have questions about the status of your complaint, please contact Michael Hurt.

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