Accessible Restroom Equipment Request Form
Submit your request for accessible restroom equipment to ensure inclusive and safe facilities.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Organization or Department
Location Where Equipment is Needed
*
Type(s) of Equipment Needed
*
Grab bars
Accessible toilet seat
Transfer bench
Raised sink
Emergency pull cord
Accessible faucet handles
Changing table (adult/child)
Accessible mirror
Other
Quantity Needed (per equipment type)
*
Accessibility Needs or Specifications
*
Date Equipment is Needed By
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Delivery or Installation Details
Usage Context (e.g., public restroom, school, office, event)
*
Please Select
Public restroom
School
Office
Event venue
Healthcare facility
Other
Additional Notes or Comments
File Upload (optional: upload site plans, photos, or supporting documents)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Request
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