City of Capitola - ADA Self-Evaluation and Transition Plan

Community Outreach Questionnaire

Please complete this questionnaire by February 28, 2025 (see submission details below)

This questionnaire is also available in alternate accessible formats upon request. Please contact the Public Works Department at 831-475-7300 or capitolaDPW@ci.capitola.ca.us to request a different format as a request for accommodations under the Americans with Disabilities Act (ADA).

The City of Capitola is gathering feedback as part of the process to develop an ADA Self-Evaluation and Transition Plan for City facilities, in compliance with the Americans with Disabilities Act (ADA).

This questionnaire is one of several ways that the City is identifying and addressing accessibility needs to improve our programs, services, and activities.

Your input will help strengthen the final recommendations for policies and procedures.

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* 1. In your experience with the City of Capitola, have you encountered physical barriers or difficulties in accessing City facilities (parks, parking lots, buildings, sidewalk or bus stops, etc.)? (Select Yes or No below)

Yes

If yes, please describe the facility and the condition(s) or situation(s) that caused the difficulty.

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* 2. Have you encountered policies or practices that make it difficult to access to City programs, services or activities? (Select Yes or No below)

Yes

If yes, please describe the policy or practice and its impact.

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* 3. Have you encountered barriers or difficulties at City facilities that prevented or complicated access to programs, activities or services provided? (Select Yes or No below)

Yes

If yes, please describe the situation(s), the response and/or outcome (if any).

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* 4. Are you aware of any successful solutions to accessibility issues that have been used at other facilities that could serve as a model for the City? (Comment box provided below)

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* 5. Do you have other suggestions for improving accessibility or mobility around or at City facilities to support full participation in programs, services or services? (Comment box provided below)

Thank you for your feedback!

Providing your contact information is optional. If you choose to do so, we may reach out with follow-up questions or notify you of future disability-related events.

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* 6. Please select one of the following (2 options provided below)

My responses are confidential

My responses may be shared publicly

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* 7. Please fill in your contact information below. Order of contact information is as follows: Name, Address, City / Town, State / Province, Zip / Postal Code, Country, Email, Phone Number

Name

Address

Phone Number

Email Address

Age

Gender

Ethnicity (Optional)

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* 8. Please describe your ability status (optional): (Comment box provided below)

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* 9. Are you affiliated with any organizations that specifically serves people with disabilities (example: California Council for the Blind, Etc.)? Please list any affiliations. (Comment box provided below)