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2. The City of Winston-Salem is currently completing a new Americans with Disabilities Act Self-Evaluation and Transition Plan. In order to enhance access to programs and services for individuals with disabilities, the City of Winston-Salem is asking for your input.
4. Name of Person Completing Form
5. Phone
7. Address
9. City
10. State
11. Zip Code
13. Name of the City of Winston-Salem Facility, Program or Service You Are Providing Input on
15. The questions have been developed to solicit input from individuals with disabilities regarding the City of Winston-Salem's efforts to provide services and accommodations for individuals with disabilities and to ask for input regarding how programs, services and activities can be more accessible for individuals with disabilities.
17. Have you ever requested an accommodation for a disability from the City?*

    1. Yes
    2. No

    1. Not Applicable
    2. Don't Know
18. Was your accommodation made by the City?

    1. Yes
    2. No

    1. Not Applicable
    2. Don't Know
20. What accommodations were made?
22. Have you experienced any exterior barriers, non-accessible areas, or non-accessible programs?*

    1. Yes
    2. No

    1. Not Applicable
    2. Don't Know
23. Please describe.
25. Have you experienced any interior barriers, non-accessible areas, or non-accessible programs?*

    1. Yes
    2. No

    1. Not Applicable
    2. Don't Know
26. Please describe.
28. Is accessible seating provided for people with disabilities at programs, community events, etc. held by the City?*

    1. Yes
    2. No

    1. Not Applicable
    2. Don't Know
29. Please describe.
31. Are you aware of any City programs, services or activities that are not accessible to individuals with disabilities?*

    1. Yes
    2. No

    1. Not Applicable
    2. Don't Know
32. Please describe.
34. Are you aware of any areas and elements of the City that are not accessible to individuals with disabilities?*

    1. Yes
    2. No

    1. Not Applicable
    2. Don't Know
35. Please describe.
37. Is information provided regarding the City’s accommodations and auxiliary aids (such as assistive listening systems, interpreters, alternate formats, specialized equipment, or assisted services, etc.)?*

    1. Yes
    2. No

    1. Not Applicable
    2. Don't Know
38. Please describe.
40. Is there adequate directional and informational signage provided at City facilities?*

    1. Yes
    2. No

    1. Not Applicable
    2. Don't Know
41. Please describe.
43. If you have requested City auxiliary aids, interpreters, or specialized equipment, was your request accommodated?*

    1. Yes
    2. No

    1. Not Applicable
    2. Don't Know
44. Please describe.
46. Do you know who to contact at the City to request accommodations for yourself, a relative, or a friend with a disability?*

    1. Yes
    2. No

    1. Not Applicable
    2. Don't Know
47. Who would you contact?
49. Is the attitude of the City (or its employees) toward you, or someone you know with a disability, generally helpful, supportive, positive and proactive in solving accessibility issues?*

    1. Yes
    2. No

    1. Not Applicable
    2. Don't Know
50. Please describe.
52. Are there any areas of the City you or someone you know with a disability cannot access?*

    1. Yes
    2. No

    1. Not Applicable
    2. Don't Know
53. Please describe.
55. What do you feel should be the highest priority for the City of Winston-Salem to improve accessibility in the City?
57. What recommendations do you have for making City services, programs or facilities more accessible?
59. Other Comments or Concerns
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61. 1. Receive an email copy of this form.
62. Email address

    This field is not part of the form submission.

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