Accessibility Feedback Form

The purpose of this form is to improve accessibility in the City. If you believe you have suffered a violation of the Americans with Disabilities Act, you should fill out the Civil Rights Complaint Form. If you currently have a case under investigation in the Civil Rights Department, please wait until investigation concludes to submit an Accessibility Feedback Form.

SUBMITTER INFORMATION

First Name

Last Name

What are your pronouns?

He/him/his

She/her/hers

They/them/theirs

Other

Permanent Street Address

City

State

ZIP Code

Email Address

Phone Number

Phone

What is your preferred method of communication?

Do you self-identify as a person with a disability?

Yes

Prefer Not to Answer

Are you submitting this feedback form on behalf of someone else?

Yes

INCIDENT DETAILS

If you have multiple incidents on different dates, please submit each incident separately.

Date of Incident

mm/dd/yyyy

Street Address of Incident

Room/Suite Number of Incident

ZIP Code of Incident

Description of Incident

Please provide a detailed description of what happened and who was involved in the incident.

AREA OF FOCUS

Please select the area(s) of accessibility barriers to which the incident relates.

Select all that apply.

What resolution to the incident are you hoping for?

Please provide photos or other evidence of the incident here.

Drop your files here

Did you submit your complaint to another agency?

Yes

Send me a copy of my responses

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