Gateway Services INC
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REASONABLE MODIFICATION COMPLAINT FORM

REASONABLE MODIFICATION COMPLAINT FORM

Section I:

Name_______________________________________________________________________

Address:_____________________________________________________________________

Telephone (Home):_______________________Telephone (Work):_____________________

Electronic Mail Address:________________________________________________________

Accessible Format Requirements? ____Large Print____Audio Tape ____TDD ____Other
 
Section II:
Are you filing this complaint on your own behalf?    ____Yes* ____No
*If you answered "yes" to this question, go to Section III.
If not, please supply the name and relationship of the person for whom you are complaining:

___________________________________________________________________________

Please explain why you have filed for a third party:______________________________
__________________________________________________________________________
 Please confirm that you have obtained the permission of the aggrieved party if you are filing on behalf of a third party.
____Yes   ____No

Section III:
Date that Reasonable Modification was Denied (Month, Day, Year):        _____________________________
Explain as clearly as possible what happened and why you believe you should have received the modification request. Describe all persons who were involved. Include the name and contact information of the person(s) (if known) as well as names and contact information of any witnesses. If more space is needed, please use the back of this form.  You may also attach other items that you think are relevant.
_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________
Section IV
Have you previously filed a complaint with this agency?  ____Yes  ____No

Signature and date required.  Please submit the form in person or via mail/email.

_____________________________________________________________________________________
Signature                                                                                                                               Date

Access Johnson County Public Transit  Attn:  Jennifer Moss, Compliance Officer
PO Box 216, Franklin, IN 46131
[email protected]


Location


Accepting Applications 

* Drivers

​* Employment Consultants

* Day Program 



Contact Us

  • Home
  • Employment Application
  • Gateway Services
    • Day Services
    • Employment Services
    • Deaf Services
    • Respite
    • About Us
    • Gallery
    • Urban TAM Plan
    • Contact Us
  • Access Johnson County
    • NOW HIRING
    • ADA Partransit Plan
    • ADA Application
    • Fares
    • Reasonable Modification Policy
    • Reasonable Mod Camplaint Form
    • Riders Guide
    • Schedules & Route Maps
    • Mission
    • Public Notice of Rights
    • Construction Updates
    • CLOSINGS
    • Ride
    • Contact Us
    • Advertise
    • Meet our Staff
    • Awards
    • Links
  • Blog
  • Access Johnson County
  • Public Notice of Rights
  • Archive Employment Application
  • Link Page