Americans with Disabilities Act Discrimination Complaint Form

OMB 1190-0009

Under title II of the Americans with Disabilities Act, an individual who believes that he or she has been subjected to discrimination on the basis of disability by a public entity may, by himself or herself or by an authorized representative, file a complaint. This information collection form has been developed to simplify this process for complainants.

The latest form for Americans with Disabilities Act Discrimination Complaint Form expires 2021-09-30 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 1190-0009 Americans with Disabilities Act Discrimination Complaint Form Form
30 day OMB 1190-0009 83 FR 28866 06 21 2018.pdf Supplementary Document
DRS title II supporting statement 1190-0009.docx Supporting Statement A
Certification Stmt 2015.doc Supplementary Document
Privacy Release_A.doc Supplementary Document
CFR Complaint.docx Supplementary Document
ADA Law 12131.docx Supplementary Document
Americans with Disabilities Act Discrimination Complaint Form Form

All Historical Document Collections

201806-1190-001 Approved without change	Extension without change of a currently approved collection	2018-06-21
201502-1190-001 Approved with change	Revision of a currently approved collection	2015-05-27
201201-1190-001 Approved with change	Extension without change of a currently approved collection	2012-01-26
201005-1190-003 Approved without change	Extension without change of a currently approved collection	2010-05-28
200701-1190-005 Approved without change	Extension without change of a currently approved collection	2007-04-18
200403-1190-001 Approved with change	Extension without change of a currently approved collection	2004-03-29
200010-1190-004 Approved without change	Extension without change of a currently approved collection	2000-10-31
199709-1190-001 Approved without change	New collection (Request for a new OMB Control Number)	1997-09-10