ADA Site Compliance for Illinois Providers

Demographic Information

Please take the time to fill out this 4 page survey on your facility/practice's ADA Site Compliance.

Question Title

* 1. Demographic Information

Physician Name

Facility

Address

Suite #

State

Zip Code

Phone Number

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* 2. Please select your Provider Type

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* 3. Provider or facility license, NPI, Medicare, Medicaid, and Tax numbers

Provider / Facility License #

Provider / Facility NPI #

Medicare # (optional - if not applicable answer "NA")

Medicaid #

Tax ID #

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* 4. Is your location in close proximity to public transportation?

Yes

Additional Information

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* 5. Language Capabilities: please select non-English Language(s), including ASL, spoken and/or enter any language(s) not listed in the "other" field.

American Sign Language (ASL)

Spanish

Polish

Chinese

Tagalog

Korean

Arabic

Russian

Italian

Greek

Hindi

No Other Languages

Other language(s) (please specify)

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* 1. Demographic Information

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* 2. Please select your Provider Type

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* 3. Provider or facility license, NPI, Medicare, Medicaid, and Tax numbers

Question Title

* 4. Is your location in close proximity to public transportation?

Question Title

* 5. Language Capabilities: please select non-English Language(s), including ASL, spoken and/or enter any language(s) not listed in the "other" field.

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* 6. Is there a Language Line Interpreter available?