Request for ADA Inspection Form

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

I wish to remain anonymous.

I do not wish to remain anonymous.

Yes

No

I do not know.

Continually

Other frequency

I do not know.

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

Office of Congressional Workplace Rights

AMERICANS WITH DISABILITIES ACT (ADA) INSPECTION FORM

See instructions for filling out this form below (page 5).

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

which they pertain.

FORM 1331

DO NOT WRITE IN THIS SPACE

Case No.

Date 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.

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.

2A. Do the barriers to access described below (page 2)

continue to exist?

2B. If they continue, how often is access b eing denied?

Please define the frequency:

3A. Name of individual filing this request:

Office:

Address:

Tel. #: Ext.

Fax #:

E-mail:

3B. Contact person(s) from these offices, if known.

Contact person:

Address:

Tel. #: Ext.

Fax #:

E-mail:

Note: If you need to list additional points of contact,

please attach additional sheets, numbered accordingly.

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

www.ocwr.gov

1