Humboldt Senior Resource Center (HSRC) is committed to providing equal access to all programs, facilities, and services in compliance with the Title III of the Americans with Disabilities Act (ADA).

If you believe you have been discriminated against because of a disability or denied access to HSRC services, you have the right to file a grievance.

Filing a Grievance

Any grievance alleging discrimination against anyone with a disability should be documented in writing on the ADA Grievance Form found below, and must contain the name, address and phone number of the grievant. The form should include as much information as possible regarding the alleged violation including date, time, location, and a clear description of the grievance, and be received by the HSRC Director of Operations no later than 60 days following the alleged incident. The ADA Grievance Form must be completed and signed by the grievant or their authorized advocate. If you are unable to submit your grievance form in writing, please contact us for assistance.

Where to File

Complaints should be directed to HSRC’s Director of Operations:

Rachael Sovereign
1910 California St, Eureka CA 95501
707-443-9747
RSovereign@humsenior.org

Resolution Process

Upon receipt, HSRC will review the completed ADA Grievance Form within 10 days. If the form requires additional information, we will contact the complainant and return the form for completion. Once the completed form has been received, a written response will be provided within 30 business days outlining findings and any actions to be taken.

Appeals

If you are not satisfied with the response, you may appeal in writing to HSRC’s Chief Executive Officer within 15 business days. A final decision will be issued within 20 business days.

Nothing in this grievance procedure prevents an individual from filing a complaint with the Department of Justice ADA Enforcement.

All written and/or recorded communications will remain on file with HSRC for a period of 5 years.

ADA Grievance Form

Humboldt Senior Resource Center (HSRC) is committed to ensuring equal access to programs, services, and employment opportunities in compliance with the Americans with Disabilities Act (ADA). If you believe you have been discriminated against based on disability, please complete this form.

Section I

Name:

Address:

City/State/Zip:

Phone:

Email:

Section II

Are you filing this complaint on your own behalf?

If you answered “yes” to this question, please go to Section III
If no, please supply the name and relationship of the person for whom you are filing:

Name:

Relationship:

Have you obtained permission from this person?

Section III

If you believe you were discriminated against based on a disability, please provide as much detail as possible regarding the incident:

Date:

Time:

Location:

Individuals involved (if known):

Explain as clearly as possible the incident or barrier you experienced:

Section IV

Please describe what action or outcome you are seeking:

Signature: Date:

Please return the completed form to HSRC’s Director of Operations:

Rachael Sovereign
1910 California St, Eureka CA 95501
707-443-9747
RSovereign@humsenior.org