Accessibility Feedback Form Accessibility Feedback Date of Your Visit(Required)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Time of Your Visit(Required) Hours : Minutes AM PM AM/PM Staff Member, Department or Service Location you visited(Required) Did we respond to your customer service needs today?(Required) Yes No Was our customer service provided to you in an accessible manner? Yes Somewhat No If you answered ‘no’, to the previous question, please explain.Did you have any problems accessing our goods and services? Yes Somewhat No Please explain any problems you may have had accessing our goods and servicesAdditional CommentsName First Last Email(Required) Phone