City of Winston-Salem | ADA Survey Form for Individuals

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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.

Americans with Disabilities Act Survey Form

Name of person completing form (optional)

Address (Optional)

Phone (Optional)

Name of the City of Winston-Salem facility, program or service you are providing input on

The following 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.

1. Have you ever requested an accommodation for a disability from the City?
Yes
No
Not Applicable
Don't know

2. If an accommodation was requested, was your accommodation made by the City?
Yes
No
Not applicable
Don't know

If yes, what accommodations were made?

3. Have you experienced any *exterior* barriers, non-accessible areas, or non-accessible programs?
Yes
No
Not applicable
Don't know

If yes, please describe.

4. Have you experienced any *interior* barriers, non-accessible areas, or non-accessible programs?
Yes
No
Not applicable
Don't know

If yes, please describe.

5. Is accessible seating provided for people with disabilities at programs, community events, etc. held by the City?
Yes
No
Not applicable
Don't know

If no, please describe.

6. Are you aware of any City programs, services or activities that are not accessible to individuals with disabilities?
Yes
No
Not applicable
Don't know

If yes, please describe.

7. Are you aware of any areas and elements of the City that are not accessible to individuals with disabilities?
Yes
No
Not applicable
Don't know

If yes, please describe.

8. 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.)?
Yes
No
Not applicable
Don't know

If no, please describe.

9. Is there adequate directional and informational signage provided at City facilities?
Yes
No
Not applicable
Don't know

If no, please describe.

10. If you have requested City auxiliary aids, interpreters, or specialized equipment, was your request accommodated?
Yes
No
Not applicable
Don't know

If no, please describe.

11. Do you know who to contact at the City to request accommodations for yourself, a relative, or a friend with a disability?
Yes
No
Not applicable
Don't know

If yes, who would you contact?

12. 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?
Yes
No
Not applicable
Don't know

Please describe your previous answer.

13. Are there any areas of the City you or someone you know with a disability cannot access?
Yes
No
Not applicable
Don't know

If yes, please describe.

14. What do you feel should be the highest priority for the City of Winston-Salem to improve accessibility in the City?

15. What recommendations do you have for making City services, programs or facilities more accessible?

16. Other comments or concerns

Thank you for your input. Comments can also be made by e-mail to angelac@cityofws.org or by phone to 336-747-7404 or alana@cityofws.org or by phone at 336-747-7401 or fax to 336-748-3816.

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