City of IGH Form Center

2. Name*
3. Email Address*
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone*
13. Name of Alternate Contact Person*
14. Telephone Number of Alternate Contact Person*
16. Address of Alternate Contact Person*
18. City of Alternate Contact Person*
19. State of Alternate Contact Person*
20. Zip Code of Alternate Contact Person*
22. Department Alleged to Have Denied Access*
23. I was denied access on*
    I was denied access on
25. Disability Statement: My disability is*
26. This problem is:*

    1. Temporary
    2. Permanent
28. I am seeking access to the following City of Inver Grove Heights program or activity in which I haven’t Been able to participate because I need an accommodation:*
30. Proposed Access or Accommodation*

    Incident or Barrier: Please describe the particular way in which you believe you have been denied the benefits of any services, program, or activity or have otherwise been subjected to discrimination.

    Please specify dates, times, and places of incidents and names and/or positions of agency employees involved; if any, as well as names, addresses, and telephone numbers of any eyewitnesses to any such incident. Attach additional pages if necessary. Include a description of the way in which you feel access may be facilitated to the benefits described above or the way in which accommodations could be provided to allow access.

32. Contact Information

34. City Programs & Services

    Julie Dorshak, Recreation Superintendent
    Email Julie Dorshak
    Phone: 651-450-2587

    8055 Barbara Avenue
    Inver Grove Heights, MN 55077

35. Employment

    Janet Shefchik, Human Resources Manager
    Email Janet Shefchik
    Phone: 651-450-2512

    8150 Barbara Avenue
    Inver Grove Heights, MN 55077

37. Submit this completed form to the appropriate ADA Coordinator:*

    1. City Programs and Services: Julie Dorshak, Recreation Superintendent
    2. Employment: Janet Shefchik, Human Resources Manager
Leave This Blank:


39. 1. Receive an email copy of this form.
40. Email address

    This field is not part of the form submission.

41. Submit

* indicates a required field