Barrier Removal Request Form

If you are an individual with a disability that has encountered a physical or structural barrier located within the City right-of-way and wish to make the City aware of the problem, please complete the form/questionnaire below.

Barrier Removal Request

Please complete the entire questionnaire. Please note, if the information you provide is incomplete or the City has questions about your request, we may not be able to fully investigate if we cannot contact you. If you need assistance with filling out the below questionnaire, please contact the Accessibility Program or call at (541) 693-2198.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Email(Required)

Phone(Required)

Address/Location of Physical or Structural Barrier

Street where barrier exists:(Required)

Nearest cross street where barrier exists:(Required)

Starting location: (address, district, neighborhood, etc.)(Required)

Destination location: (address, district, neighborhood, etc.)(Required)

Enter the location you are/were trying to get to.

Barrier Removal Request Description

Describe how the barrier impacted or affected your ability to travel within the City right-of-way. Please be specific as to how the barrier is affecting the person with a disability (if not self) in traveling in the City's right-of-way. Provide destination location if applicable.(Required)

For example, the barrier is preventing the ability of the person to get to a bus stop, shopping center, park, etc.

Please upload any additional documents or photos to support your barrier removal request.

Accepted file types: gif, jpg, jpeg, png, doc, docx, xls, xlsx, rtf, pdf, txt, Max. file size: 128 MB.

Contacts

Cassandra Kehoe (She/Her)
Accessibility & Equity Manager and COBAAC Staff Liaison 541-693-2141 ckehoe@bendoregon.gov
Have a question about Accessibility?
Emails sent to this address go to an inbox accessible by Accessibility Program staff. 541-693-2198 accessibility@bendoregon.gov

Barrier Removal Request Form