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 an email copy of this form.
57. Email address

    This field is not part of the form submission.

58. Submit

* indicates a required field