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AIR TRAVEL - For reporting incidents believed to constitute discrimination against a passenger with a disability or a violation of DOT's accessibility rules under the Air Carrier Access Act (14 CFR Part 382).

U.S. Department of Transportation
Aviation Consumer Protection Division , C-75-D
400 Seventh Street, S.W.
Washington, DC 20590

Complaint Concerning Accessibility of Airline Service
(Passengers with Disabilities)

For reporting incidents believed to constitute discrimination against a passenger with a disability or a violation of DOT's accessibility rules under the Air Carrier Access Act (14 CFR Part 382). Please complete this form and mail it to the above address. Please type, write legibly, or print, in black ink. You may wish to keep a photocopy of this form. If available, enclose a copy of your airline ticket or travel agency itinerary sheet.

Passenger Information
Name: __________________________________________________________________________
Street Address: ________________________________________________________________
City: ________________________________________ State: ________ Zip: ____________
Telephone: Home:(with area code) ___________________________ Business: _________
E-mail address (if any): ____________________________________________
Person to contact about this complaint, if other than the passenger:
Name: _______________________________________________________________________
Street Address: ________________________________________________________________
City: ________________________________________ State:______Zip:______________
Telephone: Home:_________________________ Business: _____________________
E-mail address (if any): ____________________________________________

Flight Information List only the flight(s) on which the discrimination or accessibility problems occurred.

Date Airline Flight number
From (city)To (city)


PRIVACY ACT STATEMENT: The authority for collecting this information is contained in 49 U.S.C. 46101. We need this information in order to investigate your complaint. The personal information will be used primarily for enforcement and compliance purposes. The Department will not disclose the name or other identifying information about an individual unless it is necessary for enforcement activities against an entity alleged to have violated Federal law, or unless such information is required to be disclosed under the Freedom of Information Act, 5 U.S.C. 552, or as is allowed through the publication of a routine use in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. To further the Department's enforcement activities, information we have about you may be given to appropriate Federal, State, or local agencies. Additional disclosures of information may be made to members of Congress or its staff; to volunteer student workers within the Department of Transportation so that they may perform their duties; to the news media when release is made consistent with the Freedom of Information Act and 49 CFR Part 7; and to the National Archives and Records Administration and General Services Administration to perform records management inspection functions in accordance with their statutory responsibilities. Furnishing of the requested information is voluntary, except that the failure to provide such information may result in our being unable to process your complaint.
Issued 4/99


DOT Use

Case number: Date logged: Complaint code:


I. Describe the incident (including where it occurred). If possible, include the names of those involved, or of any witnesses. Describe the nature of the disability and any accommodations that were required. Provide details (including dates) of any contacts prior to the flight date in which assistance was requested. State when the passenger checked in for the flight(s). If you already have a letter or other written statement that includes this information (see next section), you may simply enclose it rather than completing this section.
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II. Resolution Describe any efforts to resolve the complaint through the airline's Complaint Resolution Official (CRO) or other airline staff. Enclose copies of any correspondence to or from the airline.
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III. Other Action Have you filed or do you plan to file a complaint about this incident with a court or another agency? Yes No

If yes, please provide details, including the name, complete address and telephone number of the court or agency and the date that any complaint or court action was filed.

Enclose copies of any correspondence or filings with courts or other agencies.
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