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Today's Date 	                           	  (month day year)

Your Name:

Address, Phone, Email:



May we (ILRC) contact you by phone or email if further information is needed? 
_______Yes     _______No

Name of Facility/Event/Program where barrier occurred:


Location, & Phone Number where barrier occured:



Did a Person Refuse Access?    _______ Yes           ________No

Did You Have a Contact Name or Title?:   ____________________________

Date When It Happened: __________________  (month day year)

Did the Lack of Access cause:
	Failure to receive Services
	Delay in receiving Services
	Loss of Services

Please Circle All the Next Areas that apply. 

What Type of Barrier?:
1. Physical/Exterior Access
2. Physical/Interior Access
3. Communication Access
4. Attitudinal Barrier
5. Issue Involving Service Animals


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What Type of Service?

1. Health Care Access: 
Outpatient: Doctors office, clinic, or other facility
Inpatient: Hospital or other facility
		Mental Health Services
Crises or Emergency Medical Response Services
Substance Abuse Services 
Assistive Technology/Durable Med Equipment
Health care/Insurance Information

2. Public Accommodation:
Retail Store
Restaurant
Restroom
Gym Equipment
Social/Community Service Program
Participation in an Event

3. Housing
	Housing Rental
	Housing Purchase
	Home Modification 

4. Employment/Employer

5. Educational Facility

6. Local Government Services
Police, Fire, Voting, etc.

Give Brief Statement:
Describe The Experience/Situation/Issue.  Use Detail.  Explain what happened.  

Systems Change Advocacy  "No Barriers"  Access Complaint Form 


Return form to mjust@ilrc-trico.org or mail to
ILRC, Inc. Attn MJust 423 W. Victoria St, Santa Barbara, CA 93101