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Americans with Disabilities Act (ADA) Survey Form for Individuals

  1. 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.
  2. 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.
  3. Have you ever requested an accommodation for a disability from the City?*
  4. Was your accommodation made by the City?
  5. Have you experienced any exterior barriers, non-accessible areas, or non-accessible programs?*
  6. Have you experienced any interior barriers, non-accessible areas, or non-accessible programs?*
  7. Is accessible seating provided for people with disabilities at programs, community events, etc. held by the City?*
  8. Are you aware of any City programs, services or activities that are not accessible to individuals with disabilities?*
  9. Are you aware of any areas and elements of the City that are not accessible to individuals with disabilities?*
  10. 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.)?*
  11. Is there adequate directional and informational signage provided at City facilities?*
  12. If you have requested City auxiliary aids, interpreters, or specialized equipment, was your request accommodated?*
  13. Do you know who to contact at the City to request accommodations for yourself, a relative, or a friend with a disability?*
  14. 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?*
  15. Are there any areas of the City you or someone you know with a disability cannot access?*
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  17. This field is not part of the form submission.