ADA Comment/Complaint Form

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.

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: Oahu Transit Services, Inc., Compliance Officer, 811 Middle Street, Honolulu, Hawaii 96819.

SECTION I: TYPE OF COMMENT
Is this related to a Reasonable Modification: [ ] Yes [ ] No If you answered yes, has a request for a modification been previously submitted? [ ] Yes [ ] No
SECTION II: CONTACT INFORMATION
Salutation [Mr./Mrs./Ms., etc.]:
Name:
Street Address:
City, State, Zip code:
Phone:			Email:
Accessible Format Requirements:	[ ] Large Print		[ ] TDD/Relay	[ ] Audio Recording	Other:
SECTION III: COMMENT DETAILS
Transit Service (Choose One) [ ] Bus [ ] Paratransit
Date of Occurrence:			Time of Occurrence:
Name/ID of Employee(s) or Others Involved:
Vehicle ID/Route Name or Number:
Direction of Travel:
Location of Incident:
Mobility Aid Used (if any):
If above information is unknown, please provide other descriptive information to help identify the employee:
Description of Incident or Message:
SECTION IV: FOLLOW-UP
May we contact you if we need more details or information?				[ ] Yes	[ ] No
What is the best way to reach you? (Choose One)*		[ ] Phone		[ ] Email	[ ] Mail
If a phone call is preferred, what is the best day and time to reach you?
SECTION V: DESIRED RESPONSE (Choose One)*
[ ] Email response [ ] Telephone response [ ] Response by U.S. Postal Mail