Accessibility Barrier Report Form

Background Information

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Your full name:

Your Affiliation with Mid:

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Example: student, faculty, staff, vistor

Your phone number:

Your email address:

Email address must be of a valid format.

Nature of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Location of incident(Required):

This field is required.

Please list individuals and/or departments involved below

Name or Organization

Person/Department/Areas role

ID Number

Phone number

Email address

Questions

Please answer the question that best addresses the barrier you are reporting. Provide as much detail and information as possible.

If you are reporting a physical barrier, indicate the barrier and location below. Physical barriers may include issues such as difficulties with building access (classroom/office/entrances), problems with carpets, door handles, bathrooms, drinking fountains, elevators, outside grounds (sidewalks/curbs, ramps, snow drifts), etc. This field is required.

If you are reporting a technology barrier, indicate the barrier experienced below. If reporting a webpage barrier it is helpful if you include the URL. If reporting online class barrier, include the class section. Technology barriers may include items such as websites, online course sites, software, hardware or multi-media. This field is required.

If the barrier you wish to report is something other than a physical or technology barrier, describe the barrier and location below. This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Please list individuals and/or departments involved below

Questions

Supporting Documentation

Submission