Accessibility Complaint Form

Your first name

Your last name

Your Street Address

Your Street Address Line 2

Your City

Your State

Your Zip Code

Your Country

Your Phone Number

Your Email

Name and location of building or business you believe to be inaccessible

Have you contacted anyone else about this?

Yes No

Please describe how this impacts you. Be specific. If you Are not personally affected by a disability, your complaint May not be pursued.

Below are some possible accessibility problems. Please check all that you feel are applicable to this complaint. List any Other areas you believe pose a barrier to accessibility. Please be as specific as possible.

No designated parking spaces Too few designated parking spaces Improperly designated parking spaces No accessible route of travel from designated spaces to entrance Entry doors are too heavy Door handles are not easy to open (lever type) No accessible route of travel inside the building Public restrooms are not accessible Other barriers to accessibility:

Other barriers to accessibility:

Please choose an option from the information below.

OPTION 1: I give my permission for the Catskill Center for Independence to use my name when investigating this complaint. I am interested in working with the staff of the Center to resolve the issue. OPTION 2: I DO NOT give my permission for the Catskill Center for Independence to use my name when investigating this complaint. But I am interested in working with the staff of the Center to resolve the issue. OPTION 3: I DO NOT give my permission for the Catskill Center for Independence to use my name when investigating this complaint and I am not interested in working with the staff of the Center to resolve the issue.