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ADA  Comment/Complaint  Form  ADA 留言／投诉表       

The American with Disabilities Act (ADA) prohibits discrimination against all qualified disabled individuals in public services, programs, and activities. The City & County of Honolulu, Department of Transportation Services, and Oahu Transit Services are committed to ensuring that no qualified disabled person is discriminated against while using TheBus or TheHandi-Van as prohibited by ADA.

The American with Disabilities Act 美国残疾人法案(ADA)禁止在公共服务、计划或活动中歧视任何符合资格的残疾人。檀香山市县、交通运输服务部、以及欧胡岛交通运输服务部门致力于遵循ADA禁止条例以保证所有符合资格的残疾人在使用TheBus（公交车）或TheHandi-Van（残障人士小巴）时不受歧视。

Please provide the following information necessary in order to process your complaint. Assistance is available upon request. Complete this form and mail or deliver to:

请提供以下所需信息以便我们处理您的投诉。我们可应要求提供协助。请完整填写这张表格并邮寄或递交至： Oahu Transit Services, Inc., Compliance Officer, 811 Middle Street, Honolulu, Hawaii 96819.


SECTION I: TYPE OF COMMENT 第一部分(I)：留言类型

Is this related to a Reasonable Modification: [ ] Yes 是 [ ] No 否

这是否与合理改动有关

If you answered yes, has a request for a modification been previously submitted? [ ] Yes 是 [ ] No 否

如果回答是，改动要求是否在事前已提交？

SECTION II: CONTACT INFORMATION 第二部分(II)：联系信息

Salutation 称呼

[Mr./Mrs./Ms., etc.]:

Name

姓名:

Street Address

街道地址:

City, State, Zip code

城市，州，邮政编码:

Phone

电话:

Email

电子邮件:

Accessible Format Requirements

无障碍模式要求:


[ ] Large Print

大字


[ ] TDD 听障人士专线/

Relay 转接


[ ] Audio Recording

语音录音

Other 其他:

SECTION III: COMMENT DETAILS 第三部分(III)：留言细节

Transit Service (Choose One) [ ] TheBus 公交车 [ ] TheHandi-Van 残障人士小巴交通服务（请选择一项）

Date of Occurrence:

发生日期：

Time of Occurrence:

发生时间：

Name/ID of Employee(s) or Others Involved:

工作人员或涉及人员姓名／工作证号 ：

Vehicle ID/Route Name or Number:

车辆识别号/路线名或路线号 ：

Direction of Travel

行进方向 ：

Location of Incident

事件地点 ：

Mobility Aid Used (if any)

使用的行动帮助（如果有）

If above information is unknown, please provide other descriptive information to help identify the employee:

如果不知道以上信息，请提供其他描述性信息以帮助我们辨识工作人员 ：

Description of Incident or Message 事件描述或讯息 ：

SECTION IV: FOLLOW-UP 第四部分(IV)：后续措施

May we contact you if we need more details or information?

如果我们需要更多细节或信息，可否联系您？

[ ] Yes

是

[ ] No

否

What is the best way to reach you? (Choose One)*

最好联系到您的方式（请选择一项）*

[ ] Phone

电话

[ ] Email

电子邮件

[ ] Mail

邮件

If a phone call is preferred, what is the best day and time to reach you?

如果希望以电话方式联系，请说明最好哪天、什么时间可联系到您。


SECTION V: DESIRED RESPONSE (Choose One)* 第五部分(V): 希望答复方式（请选择一项）*


[ ] Email response 电子邮件答复


[ ] Telephone response 电话答复


[ ] Response by U.S. Postal Mail 美国邮政邮件答复