2. 
5. 
   

   UNIVERSAL CITY, TEXAS
   TITLE II ADA GRIEVANCE FORM

7. Instructions:

   Please complete and sign the form and email or mail it to Universal City within 60 calendar days of any incident.

9. Physical Address:
   Justin Garcia, ADA/504 Coordinator	Phone: 210-659-0333 ext. 788
   Fire Marshal / Asst. Chief	Email: jgarcia@uctx.gov
   2150 Universal City Blvd
   Universal City, TX 78148

11. Type of Grievance (Check all that apply):*

    1. Accommodation Request
    2. Program/Service
    3. Facility Accessibility
    4. Other
13. If other is selected:

15. Contact Information

17. Reporting Individual:
19. First Name*
20. Last Name*
22. Address 1*
24. Address2
26. City*
27. State*
28. Zip*
30. Contact Information is required.

    If no phone number is available, an email must be provided below.

32. Phone: Enter 0 (zero) if none.*

    If 0 is entered, an email must be required.  

34. Alternate Phone:
36. Email:
38. Do you have an authorized representative for this grievance?*

    1. Yes
    2. No
40. First Name
41. Last Name
43. Address1
45. Address 2
47. City
48. State
49. Zip

51. Details of Complaint/Incident

53. Date/Time:*
    Date/Time:

    Please provide date/time of the incident.

54. Time:
    Time:
56. Department/Facility/Location Involved:*
58. Describe Incident:*
60. Resolution of Complaint:*
62. Remedy Sought:*
64. Signature*
65. Date:*
    Date:
Leave This Blank:


67. 1. Receive an email copy of this form.
68. Email address

    This field is not part of the form submission.

69. Submit Submit and Print

* indicates a required field