Submit a Form : ADA Complaint Form

Fill out the following form to submit an Americans With Disabilities (ADA) complaint

Brushy Creek Municipal Utility District (“Brushy Creek”) is committed to complying with all state and federal disability laws, such as the Americans with Disabilities Act, as amended (“ADA”). Brushy Creek does not permit retaliation against anyone for exercising rights protected by the ADA or other law protecting persons with a disability.

If you, or someone you are acting on behalf of, need a reasonable modification to accommodate a disability or an auxiliary aid or service to ensure effective communication, or have any other question or concern regarding access to Brushy Creek’s services and programs for persons with disabilities, please complete and submit this form.

This form is available in alternate formats (large print, Braille, audio, or electronic format) upon request. Alternative means of filing requests will be made available if necessary. For more information, if you need help making your request, or if you wish to make your request orally, contact the District’s ADA Coordinator:

Bradley Holsapple, Parks & Facilities Manager

Brushy Creek Municipal Utility District

16318 Great Oaks, Round Rock, TX 78681

ADA@bcmud.org

512-255-7871 x226

The ADA Complaint should be submitted as soon as possible but no later than 60 days after the incident giving rise to the complaint. If for any reason the complaint is not satisfactorily resolved within 30 days after submission of the complaint, the individual and/or designee may appeal to Brushy Creek’s General Manager who can be reached at s.dalton@bcmud.org. The General Manager will issue a written decision within a reasonable timeframe.

Individuals with speech or hearing loss may call Relay Texas toll free 7-1-1. (More information available at www.relaytexas.com).

ADA Complaint Form

SECTION 1: Complaintant Information

If this request is made on behalf of another person who does not wish to remain anonymous, please provide that person's:

What is your relationship (optional, no specific relationship is required to make a request on behalf of a person with a disability)?

The individual on whose behalf this complaint is submitted authorizes Brushy Creek to communicate with the person submitting this form.

Section 2: Reason for complaint

Describe your complaint, including the identity of the service, activity, program, orbenefit at issue and the how a person with a disability was affected. Please also providein your description specific dates, times, and places, as well as the names (and contactinformation, if known) of any and all persons who may have witnessed or been involvedin the act or basis of your complaint. (Attach additional information in the file uploader below, if needed).

Disability-related information will be kept confidential and shared only with staff who need the information to investigate or resolve this complaint.

Have you filed a complaint regarding this situation with any other Federal, State, orlocal agency or court?

Section 3: Suggested Resolution

Describe your suggested outcome or resolution. Please be as specific as possible (e.g.,accessible seating, materials in accessible format, ASL interpreter, etc.)