Intake Form for a Facility Assessment
Please complete this form to the best of your ability. If you have multiple facilities, please fill out this form for each one. When you complete this form and press "submit" you should be redirected to a page with a link to repeat this form. You will also receive an email with a PDF version of this form attached for your records.
Facility Name
*
Address
*
Contact
*
First and Last name
Phone
*
Best number to reach you during business hours
Format: (000) 000-0000.
Email
*
example@example.com
Are you the owner?
*
Yes
No
If no please specify
What is the use of the facility?
*
Private Business or Nonprofit
Private Multi-Family Housing
Public (Goverment) Housing
State, County or City Government
What year was the facility originally constructed?
*
If unsure, your best estimate
Have there been any additions or alterations to the facility since 1991?
*
Yes
No
Unknown
Is this part of any litigation or potential lawsuit?
*
Yes
No
Unsure
Number of buildings
*
Number of stories per building:
Building 1
*
Building 2
Building 3
Building 4
Number of entrances per building:
Building 1
*
Building 2
Building 3
Building 4
Number of public elevators
*
Number of ramps
*
How many public restrooms are there?
*
Number of multi-stall restrooms
Number of single-user toilet rooms
How many total parking stalls serve the facility
*
Please tell us your budget for this facility assessment
*
Do you have any additional training or technical assistance requests?
Any Additional Comments or Items of Note:
Submit
Should be Empty: