MCIL Accessibility Survey

Date:

Name of Building:

Address of Building:

City:    County: Zip:

Is this building newly constructed?  Yes   No

Has this building been renovated? Yes  No

Describe the building (e.g. museum, bank, theater, retail store):

Below are some possible problems. Mark the ones that apply and briefly describe them in the space provided below.

1. No accessible path of travel

2. No accessible entrance

3. No access to the second floor

4. No access in bathroom facilities

5. Doors too heavy or not wide enough

6. No handicapped parking

7. No curbcuts

8. Other problem

Your name:

Your address:

Your phone number:

Your email address: