Americans with Disabilities Act (ADA) complaint form

Part A: Complainant Information

Name *

Street Address

Apartment, suite, etc

City

State

ZIP

Home Phone

Cell/Mobile Phone

Email Address

Consent *

I certify that the information in this application is true and correct. I understand all information will be kept confidential.

Date *

Part B: Paratransit Eligibity Complaint

ADA regulations specify who is to be determined ADA paratransit eligible. Transit agencies, with input from the communities they serve, develop their specifics of their own eligibility processes. Disability alone does not determine paratransit eligibility. Paratransit eligibility is based on an applicant’s functional ability to use fixed route service and is not a medical decision. *Denied your initial request for paratransit eligibilityDenied your recertification request for paratransit eligibilityGranted you less than full eligibility (e.g., conditional, trip-by-trip or temporary)

Clearly explain what happened and why you believe you were discriminated against. *

Part C: Paratransit On-time Performance Complaint

ADA regulations prohibit transit agencies from limiting ADA complementary paratransit service to eligible individuals by means of a “pattern or practice” — or a substantial number — of untimely pickups, trip denials, lengthy trips, and other operational practices.

Untimely pickupsMissed tripsTrip denialsLengthy tripsOther

Date

Pick Up Time

Hours

Minutes

Pick Up Time:

Hours

Minutes

Drop Off Time

Drop Off Location

Comments

Part D: Other

Clearly explain what happened and why you believe you were discriminated against.

Attach any documentation that is relevant to this complaint.

No file chosen

Form may be hand delivered, faxed or emailed to:
JTRAN Administrative Office
1785 Highway 80 West
Jackson, MS 39204
Fax: 601.326.5416
Email: transitstaff@city.jackson.ms.us

If you need to contact customer service, please call 601-960-1887

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