Disability Access in Healthcare Facilities Survey
Help us assess and improve accessibility for individuals with disabilities in healthcare environments.
Name of Healthcare Facility
*
Type of Facility
*
Please Select
Hospital
Clinic
Rehabilitation Center
Primary Care Center
Urgent Care
Other
Which of the following accessibility features are available at this facility? (Select all that apply)
*
Wheelchair ramps
Accessible parking spaces
Automatic doors
Elevators with accessible controls
Accessible restrooms
Braille or tactile signage
Hearing assistance systems
Other
Please rate the overall accessibility of this facility for individuals with disabilities.
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1
2
3
4
5
What barriers or challenges to accessibility have you observed?
Do you have any suggestions for improving accessibility at this facility?
Would you like to be contacted for follow-up regarding your feedback? If yes, please provide your email address.
example@example.com
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