14 CFR Part 382 Nondiscrimination on the Basis of Disability in Air Travel (Air Carrier Access Act) (with amendments issued through July 2003)

Appendix A – Disability Complaint Reporting Form

Name of Carrier: __________________________

Submission Date: __________________________

Period of Data Collection: _____________________

Contact Person:

Name: _________________________________________________________________________________________

Telephone # (include country code if outside the U.S.): __________________________________________________

Email address: _________________________________________________________________________________

Mailing address: __________________________________________________________________________________

Total number of complaints (i.e., incidents): __________________________

REPORT OF DISABILITY-RELATED COMPLAINT DATA

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Certification Statement: I, the undersigned, do certify that this report has been prepared under my direction in accordance with the regulations in 14 CFR Part 382. I affirm that, to the best of my knowledge and belief, this is a true, correct, and complete report

Signature: _______________________________________________