Public Place Access Barrier Reporting

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Public Place Access Barrier Report

Company

This field is for validation purposes and should be left unchanged.

Advocate Name(Required)

Type of business and reason for your visit.(Required)

Date of most recent visit(Required)

MM slash DD slash YYYY

Business Address

Street Address Address Line 2 City State ZIP Code

Was anyone with you?(Required)

Yes

Will they verify how the impediments created by the barriers affected you?

Yes

Type(s) of barrier(s) you faced (check all that apply):(Required)

A) Inaccessible parking

B) Inaccessible maneuvering space at doors

C) Inaccessible grab bars at plumbing fixtures and/or transfer space

D) Inaccessible handrails on ramps or stairs

E) Cannot safely use stairs or excessively steep ramps at the facility

F) Inaccessible clear floor space at tables and controls

G) Inaccessible knee and toe clearance at sinks, tables and other fixtures

H) Inaccessible roll-in showers or seats

I) Inaccessible website lacking required accommodations for your use

J) Any other barriers affecting you which were not listed

Other barriers affecting you which were not listed.

How often are you in the immediate vicinity of the business?

When do you next intend to visit the business if the barriers affecting you are removed?

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