ADA Feedback Form

2. Section I: Type of Comment

4. Type of Comment *

   (Choose one)

   1. Compliment

   1. Suggestion

   1. Complaint

   1. Other
6. ADA related?*

   1. Yes

   1. No

10. Section II: Contact Information

12. Salutation

    (Mr./Mrs./Ms./etc.)

13. Name

15. Street address

17. City

18. State

19. Zip

21. Phone

22. Email

24. Accessible format requirements

    1. Large print

    1. TDD/Relay

    1. Audio version

    1. Other

26. If other, please describe

30. Section III: Comment Details

32. Transit service

    (choose one, as applicable)

    1. Bus

    1. Paratransit

    1. Customer service
34. Date of occurance*

35. Time of occurance*

37. Name/ID of employee and/or other involved

    If above information is unknown, please provide other descriptive information to help identify the employee.

39. Vehicle ID/Route name/Route number

40. Direction of travel

42. Location of incident*

44. Mobility aid used (if any)

46. Description of incident or message*

50. Section IV: Follow Up

52. May we contact you if we need more information?*

    1. Yes

    1. No

54. What is the best way to reach you?

    (choose one)

    1. Phone

    1. Email

    1. Mail
Leave This Blank:


56. 1. Receive email copy
57. Email address

    This field is not part of the form submission.

58. Submit

* indicates a required field