Sample Report a Barrier Form

[Note to those who would like to create a similar form: You are welcome to interact with this form. Some questions are hidden and revealed only when specific types of barriers are selected. Feel free to submit answers in order to see how it works. Of course this form should be modified to fit your particular campus needs.]

The purpose of this form is to collect information and resolve barriers related to disability access. We welcome all members of the campus community to use this form. Even if a barrier does not affect you personally, feel free to report it so that it can be resolved.

1. Contact Information *This question is required.

First Name *This question is required.

Last Name *This question is required.

Email address *This question is required.

Phone Number

4. Was the physical barrier you encountered inside a building or outside?

4. What building was the barrier in or near?

4. In which parking lot was the problem located?

4. Which category best describes the digital access barrier?

4. In which building is the technology or equipment located?

4. Please describe in detail the barrier you would like to report. *This question is required.