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Tester Registration
1
Contact Info
2
Places You Visit
3
More Info
4
Barriers
5
Disability Status
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This field is for validation purposes and should be left unchanged.
Legal Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
List all places you visit regularly (over 6 days per year), including the city, state, visitation frequency and your primary reason for these visits.
Visited Places
Location Name
Location City
Location State
Actions
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Entries.
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More Info
Do you drive?
(Required)
Yes
No
Do you own a car?
(Required)
Yes
No
Do you have a service animal?
(Required)
Yes
No
Do you require a screen reader or other assistive device to use a computer or cell phone?
(Required)
Yes
No
Are you deaf?
(Required)
Yes
No
Do you always, sometimes, or never use a mobility device to ambulate?
(Required)
Always
Sometimes
Never
Check all barriers to you accessing public accommodations from the following list:
A) Require accessible parking
B) Require maneuvering space at doors
C) Require grab bars at plumbing fixtures and/or transfer space
D) Require handrails on ramps or stairs
E) Cannot safely use stairs or excessively steep ramps
F) Require clear floor space at tables and controls
G) Require knee and toe clearance at sinks, tables and other fixtures
H) Require roll-in showers with seats to bathe
I) Website use requires accommodations
J) Other barriers faced not listed above
Other Barriers
Disability status (check all that apply)
(Required)
Visual Impairment(s)
Motor / Physical
Cognitive / Neurological
Auditory Impairment(s)
Visual Impairments (check all that apply)
(Required)
Blindness
Low Vision
Color Blindness
Motor / Physical Impairments (check all that apply)
(Required)
Tremors
Limited Dexterity
Cognitive / Neurological Impairments (check all that apply)
(Required)
ADHD
Dyslexia
Learning Disabilities
Auditory Impairments (check all that apply)
(Required)
Deafness
Hearing Loss
Terms and Conditions
(Required)
By submitting this form, I confirm all information given is accurate.
I confirm that I have read and understood the terms outlined above.
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