Hospital Accessibility Design Evaluation Form
Please complete this form to evaluate the accessibility features and design of the hospital environment.
Evaluator Name
*
First Name
Last Name
Evaluator Email Address
*
example@example.com
Hospital Name and Location
*
Which areas of the hospital are you evaluating?
*
Main Entrance
Reception/Waiting Area
Patient Rooms
Restrooms
Elevators/Lifts
Corridors/Hallways
Other
Please rate the accessibility of the following features:
*
Rows
Signage Clarity
Wheelchair Access
Accessible Restrooms
Elevator/Lift Accessibility
Parking Accessibility
Excellent
1
2
3
4
5
Good
6
7
8
9
10
Fair
11
12
13
14
15
Poor
16
17
18
19
20
Overall, how would you rate the hospital's accessibility design?
*
1
2
3
4
5
Additional Comments or Suggestions
Submit Evaluation
Should be Empty: