EmailMe Form - NorthEast Neighbors Sidewalk Survey

Name *
First Last
Email *
Address of Sidewalk *
Have you reported this location
to the city? *
Yes
No
If YES, when?
MM / DD / YYYY
Have you ever been injured on a city sidewalk? *
Yes
No
If YES, when?
MM / DD / YYYY
If you have been injured,
did you report it to the city? *
Yes
No
If YES, when?
MM / DD / YYYY
Have you filed an ADA complaint
for this location? *
Yes
No
If YES, when?
MM / DD / YYYY
Additional Information

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