ACCESSIBLE CUSTOMER SERVICE FEEDBACK FORM

Required fields are marked with asterisks (*)

Providing Goods and Services to People with Disabilities

Name

Telephone Number (If you prefer that we contact you by telephone please enter a telephone number where we can reach you during the day)

E-mail Address

Please tell us the date of your visit.

Please tell us the time of your visit.

Staff member, Department or Service you visited?

Did we respond to your customer service needs on that date and at that time?

Yes

Was our customer service provided to you in an accessible manner?

Yes

Somewhat

If you answered no please explain why.

Did you have any problems accessing our goods and services?

Yes

Somewhat

If you had any problems accessing our goods and services please explain why.

Thank you for submitting the Accessible Customer Service Feedback Form.

Someone from the City will contact you within 3 business days.