Request for ADA Inspection Form

• Legal Form Number: 1331
• Section: Office of Congressional Workplace Rights (United States)

advancing workplace rights, safety and health, and accessibility in the legislative branch

Officeof CongressionalWorkplaceRights

Room LA-200, John Adams Building · 110 Second Street, SE · Washington, DC 20540-1999 · t/202.724.9250 · f/202.426.1913

ocwr.gov

1

AMERICANS WITH DISABILITIES ACT (ADA)INSPECTION FORM

See instructions for filling out this form below (page 3).

Attach additional sheets if needed, numbered according to the box(es) to which they

pertain.

DO NOT WRITE IN THIS SPACE

Case No.

FORM 1331Date Filed

1. I am requesting this inspection because I believe that access to a public service, program, activity, accommodation, or facility

covered by the Congressional Accountability Act has been or is being denied to persons with disabilities.

I wish to remain anonymous.

I do not wish to remain anonymous.

Note: If you wish to remain anonymous, your name will not be revealed to others unless the Office of Congressional Workplace

Rights (OCWR) is explicitly notified in writing.

2. Description of how access is being denied. Describe the public service, program, activity, accommodation, or facility, and

explain how access has been or is being denied to persons with disabilities. Please provide as much information as you can about

the problems encountered, including a description of the barriers encountered (such as problems entering a building or area,

communication difficulties, or any other ways participation in or use of the service, program, activity, or accommodation was

limited) and the location (building name, street address, room number, or area) where access was denied to persons with

disabilities, if applicable. Additional or supporting information may be attached if needed, numbered accordingly.

Date(s) problems were encountered: