ADA Discrimination Complaint Form

Lutheran SeniorLife will assure that no qualified individual shall, on the basis of their disability, be excluded from participation in, be denied benefits of, or be subjected to discrimination under any of its programs, service or activities as provided by Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990.

Furthermore, Lutheran SeniorLife further assures that every effort will be made to ensure nondiscrimination in all of its federally funded program activities.

Any person believing they have been discriminated against based on disability should fill out the form below. If you have other information that may be relevant to your complaint, please download the ADA Discrimination Complaint Form and mail the completed form to the Corporate Compliance Officer.

You can direct mail the form to: Lutheran SeniorLife; Corporate Compliance Officer; 191 Scharberry Lane Mars, PA 16046.

Finally, you may also call the Corporate Compliance Hotline directly at 1-866-910-2654 to submit your complaint.

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Your Name

First

Last

Your Street Address: City, State, Zip

Telephone (Home and/or Cell):

Telephone (Work):

Person(s) discriminated against:

(If other than complainant): List all names:

Street Address, City, State, Zip:

Date of Incident:

Incident Description:

Please describe the alleged discrimination incident. Explain what happened, how you were discriminated against, and all persons who were involved. Include the name of the person(s) who discriminated against you (if known), as well as the names and contact information of any witnesses.

below. list Street

Have you previously filed an ADA complaint with this agency?

Have you filed a complaint with any other federal, state, or local agencies?

If so, list the agency, agencies, and their contact information below.

Please include contact name(s), agency, street address and phone number.

Signature and date required below:

First

Last

Todays Date

Type Name of Complainant: