Submit Location Questions

Name

First Name

Last Name

Do you require assistance from a mobility device?

Please name the device or write NA (i.e. wheelchair, walker, cane, crutches, motorized chair, prosthetics etc.)

Address of Location

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What is this location?

Restaurant, private business, public business, park, etc.

Did you have difficulty entering the location?

Example: doorway was too narrow. Stairs without wheelchair ramp at entrance etc.

Were you able to move around the inside of the location easily?

Example: isle in store was too narrow to fit through. Tables too close together making people bump your wheelchair as they walk by etc.

Were you able to use the amenities of the location?

Example: Were their tables an appropriate height or did they only offer raised seating etc.

Were you able to checkout/ pay easily?

Example: were you able to reach the credit card reader. Was the payment screen at an appropriate height for you to view etc.

Were there bars in the restroom?

Example: Were these bars in a location that was idea for your use? How many bars were there?

Was the restroom/ restroom stall large enough to comfortably use?

Example: Was the door able to close and lock easily with your wheelchair inside

If you’re using a wheelchair, were you able to turnaround (360 degrees) inside of the stall?

Was there a baby changing station in the restroom?

Please note which restroom you were using (men’s or women’s) or write NA if you choose not to answer

How was your overall feel/ were you comfortable while there?

Example: was there anything about the atmosphere that made you feel uncomfortable etc.)

Would you mind if we posted some or all of your responses under the details for this location?

Only your first name would be shared*

Additional comments of thoughts about this location?

What information would be helpful for you to know about a location that is not on this list?