1

Type of Submission:

 *

Type of Submission:(Select an Answer) Praise Suggestion Complaint Incident Other

2

ADA Related?

ADA Related?(Select an Answer) Yes No

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Comment Details:

3

Transit Service Type:

Transit Service Type:(Select an Answer) Fixed Route ACT Connect Not Sure

4

Date of Occurrence:

Date of Occurrence:

5

Time of Occurrence:

Time of Occurrence:

6

Employee Related?

Employee Related?(Select an Answer) Yes No

7

Name of Employee or Others Involved:

Name of Employee or Others Involved:

8

Route Number:

Route Number:

9

Direction of Travel ( if known ) :

Direction of Travel ( if known ) :

10

Location of event:

Location of event:

11

Mobility Aid Used:

Mobility Aid Used:

12

Description of Incident:

 *

Description of Incident:

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ACT may contact you if we need additional details or information.

13

What is the best way to reach you?

What is the best way to reach you?(Select an Answer) Phone Email Mail

14

Full Name:

 *

Full Name:

15

Email:

 *

Email:

16

Phone:

 *

Phone:

17

If by phone is preferred, what is the best day and time to reach you?

If by phone is preferred, what is the best day and time to reach you?

18

Address:

Address:

19

Accessible Format Requirements:

Accessible Format Requirements:(Select an Answer) Large Print TDD/Relay Audio Recording Other

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