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Survey for Program and Facility Users, City of Modesto Page 1 of 4 Survey for Program and Facility Users City of Modesto The City is seeking input from agencies, organizations, individuals with disabilities, and interested individuals to help the City enhance accessibility to its facilities, programs, services, and activities. Please return this survey by January 8, 2016 to Paul Liu, ADA Coordinator, City of Modesto, 1010 10th Street, Modesto, CA 95354. Comments can also be made by calling (209) 577-5282, or by email at [EMAIL REDACTED]. Surveys can also be returned to Disability Access Consultants, 2243 Feather River Boulevard, Oroville, CA 95965. Comments can also be emailed to [EMAIL REDACTED], faxed to (530) 533- 3001 or made by phone to (800) 743-7067. First Name (Optional) Last Name (Optional) Date (Optional) Address (Optional) Phone (Optional) E-mail address (Optional) Name of the City of Modesto facility, location, type of program or service for which you are providing input 1. What is your relationship to the City of Modesto? (check all that apply) ☐ Resident ☐ Visitor ☐ Contractor ☐ Employee ☐ Participant of a Program, Service or Activity ☐ Other If Other, please describe. 2. Check all programs, service or activities in which you participate at the facility, site or location. ☐ Classes ☐ Recreation ☐ Meetings ☐ Sporting Events ☐ Seminars ☐ Work (Volunteer) ☐ Work (Employee) ☐ Other If Other, please describe. 3. Do you know who to contact if you need assistance, have a concern or compliant, or need an accommodation to access a facility, service or event? ☐ Yes ☐ No If Yes, who would you contact? ---PAGE BREAK--- Survey for Program and Facility Users, City of Modesto Page 2 of 4 4. Have you ever requested an accommodation for a disability from the City? ☐ Yes ☐ No ☐ Not Applicable ☐ Don’t Know 5. 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? If no, were you given a reason why it was not provided? 6. Have you experienced any barriers, nonaccessible areas, or nonaccessible programs? (Examples: no accessible parking spaces, difficulty reaching an accessible entrance, steep ramps, uneven sidewalks, need for assistive listening device, large print, etc.) ☐ Yes ☐ No ☐ Not Applicable ☐ Don’t Know If yes, please describe. 7. Have you attended any special events in the City? ☐ Yes ☐ No If yes, did you encounter any barriers to accessibility? ---PAGE BREAK--- Survey for Program and Facility Users, City of Modesto Page 3 of 4 8. Is accessible seating provided for individuals with disabilities at meetings, classes, programs, etc. held at the facility? ☐ Yes ☐ No ☐ Not Applicable ☐ Don’t Know If no, please describe. 9. Are you aware of any programs, service or activities that are not accessible to individuals with disabilities? ☐ Yes ☐ No ☐ Not Applicable ☐ Don’t Know If yes, please describe. 10. Are you aware of any areas or elements of the facility that are not accessible to individuals with disabilities? ☐ Yes ☐ No ☐ Not Applicable ☐ Don’t Know If yes, please describe. 11. Is information provided regarding accommodations, auxiliary aids (such as assistive listening systems, interpreters, alternate formats, specialized equipment, or assisted services, etc.?) ☐ Yes ☐ No ☐ Not Applicable ☐ Don’t Know Please describe. ---PAGE BREAK--- Survey for Program and Facility Users, City of Modesto Page 4 of 4 12. Is there adequate directional and informational signage provided at the facility? ☐ Yes ☐ No ☐ Not Applicable ☐ Don’t Know If no, please describe. 13. If you have requested auxiliary aids, an interpreter or specialized equipment, was your request accommodated? ☐ Yes ☐ No ☐ Not Applicable ☐ Don’t Know If no, please describe. 14. Has the attitude of the staff of the City of Modesto towards you or someone you know with a disability been generally helpful, supportive, positive and proactive in solving accessibility issues? ☐ Yes ☐ No ☐ Not Applicable ☐ Don’t Know Please describe. 15. Other comments: 16. What do you feel is the highest priority for accessibility in the City of Modesto Accessibility Plan? Print Form Email Form