Chuukese
ADA Comment/Complaint Form ADA Memef/Taropwen Kotuur
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.
Ewe Annukun Merika ren aramas me ter (Ammerican with Disability Act) mi epeti an epwe wor kirikiringaw are nifinifin ngeni ekkewe mi ter won aninisin, prokramen are mokutukutun muun meinisin mi kuur. An City me County we pekin Transpotason me Oahu Transit repwe tumunuochu an esap wor nifinifiningaw ren fiti TheBus ika ewe Handi-Van mi mumuta ngeni ekkewe ir mi ter afen nomw non pochokunen Annukun ewe ADA.
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:
Kose mochen afatatiw ekkei poraus mi fokkun auchea ngeni foforun noum ei taropwen kotuur. Amasowano ei taropwe ka tinano ika wato ren:
SECTION I: TYPE OF COMMENT PEKIN I: SOKKUN MEMEF | ||||
Is this related to a Reasonable Modification: [ ] Yes Ewer [ ] No Aap Ei fofor mi fiti mokutukutun enenia aninis ren ewe mi ter If you answered yes, has a request for a modification been previously submitted? [ ] Yes Ewer [ ] No Aap Ika ponuan ewer, iwe mi wor ei tungor ren ei sokkun aninis afen tongeni ei pekin aninis? | ||||
SECTION II: CONTACT INFORMATION PEKIN II: PORASUOMW | ||||
Salutation [Mr./Mrs./Ms., etc.]: Met sippwe kor ngonuk | ||||
Name: Itomw | ||||
Street Address: Attresin Imwomw we | ||||
City, State, Zip code: Kinikin, Fonu, sipkot | ||||
Phone Nampan Tengwa/Tenefon: | Email Omw imen: | |||
Accessible Format Requirements Met epwe Faat ngonuk ren kapas: | [ ] Large Print Mesen mak Watte | [ ] TDD/Relay Noun Rese rong kapas Mwesinen Mak are taip | [ ] Audio Recording teipin rekoton kapas | Other Ekkoch nukun: |
SECTION III: COMMENT DETAILS PEKIN III: TICHIKIN MEMEF | ||||
Transit Service (Choose One) [ ] TheBus [ ] TheHandi-Van Pekin Wan Sai (fini ew chok) | ||||
Date of Occurrence: Pwininin Maram a fis | Time of Occurrence: Kunok a fis non | |||
Name/ID of Employee(s) or Others Involved Iten/Idin ewe chon angang(s) ika iokan repwan pachenong non: | ||||
Vehicle ID/Route Name or Number Idin ew chitosa/Iten ewe an ika nampan: | |||
Direction of Travel Ian anen fetanin ewe Sai: | |||
Location of Incident Ian e fis meia ewe feiengaw: | |||
Mobility Aid Used (if any) Aninisin feiengaw mi Kawor (ika mi wor) | |||
If above information is unknown, please provide other descriptive information to help identify the employee: Ika ese fat porausan, kose mochen awora me tichiki met ke kuna are sinei ren ei feiengaw pwe epwe fatono ion ewe chon angang: | |||
Description of Incident or Message Tichikin porausen ewe feiengaw ika porausan: | |||
SECTION IV: FOLLOW-UP PEKIN IV: MET EPWE FIS MWIRIN | |||
May we contact you if we need more details or information? Kich mi tongeni kokoruk ika pwe mi wor mettoch kopwe afata ika sopweno porausan? | [ ] Yes Ewer | [ ] No Aap | |
What is the best way to reach you? (Choose One)* Met nein ekkei anen kapas eoch ach sipwe poraus ngonuk won: | [ ] Phone Tengwa/tenefon | imen | Feito seni posto |
If a phone call is preferred, what is the best day and time to reach you? Ika Tengwa/Tenefon ena ke mochen nounou, meni ran me kunok eoch ach sipwe kokoruk non | |||
SECTION V: DESIRED RESPONSE (Choose One)* PEKIN V: PONUWAN (fini ew) | |||
[ ] Email response Ponueni non imen [ ] Telephone response Ponueni non tengwa/tenefon [ ] Response by U.S. Postal Mail Ponueni non U.S. posto non taropwe mi rechister | |||