ACCESSIBILITY COMPLAINT FORM 

 

Please provide as much information as you can about the building/service/policy you believe to be inaccessible. Once we receive the completed form we will review the information provided and contact you with any questions. A decision will then be made to determine whether the Center will address the complaint.

Thank you for your willingness to become involved in you community's accessibility.

PLEASE NOTE:
If you do not include your name, address, and telephone number, no action will be taken about the complaint.

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

 Have you contacted anyone else about this?Yes No

If yes, please provide: Name, title, and telephone number of anyone you've contacted.

Please explain how this impacts you Be specific. If you are not personally affected because of a disability your complaint my 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 parking 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:

Please provide your name, address and telephone number below:

NAME:
ADDRESS:
TELEPHONE #:
E-MAIL:

CHOOSE ONE OPTION:
  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.
  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.

I DO NOT give my permission for the Catskill Center for Indepence 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



Remember: You must include your name, address, and telephone number on this form in order for us to investigate your complaint.