Form 734-5061 "Comment, Question, Concern, or Request" - Oregon

What Is Form 734-5061?

This is a legal form that was released by the Oregon Department of Transportation - a government authority operating within Oregon. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2018;
  • The latest edition provided by the Oregon Department of Transportation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 734-5061 by clicking the link below or browse more documents and templates provided by the Oregon Department of Transportation.

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Download Form 734-5061 "Comment, Question, Concern, or Request" - Oregon

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ODOT OFFICE OF CIVIL RIGHTS
COMMENT, QUESTION, CONCERN, OR REQUEST
Contact Information
NAME
DATE
ADDRESS
PHONE
CITY, STATE, ZIP
EMAIL
If you are completing this form on behalf of another person:
REPRESENTATIVE NAME
RELATIONSHIP
EMAIL
PHONE
Issue Description
LOCATION OF SITE – ADDRESS, SITE NAME, OR DESCRIPTION
TOPICS COVERED – CHECK ALL THAT APPLY
Curb ramp
Sidewalk
Parking
Service Animal
Transit Stop
Bathroom
Pushbuttons
Crosswalk
Audible Signal
DMV
Construction Work Zone
Other:
DESCRIPTION OF CONCERN, QUESTION, COMMENT OR REQUEST – INCLUDE THE DATE IF RELATED TO A SPECIFIC INCIDENT
Resolution
DESCRIBE THE RESOLUTION YOU WOULD LIKE TO SEE
If yes, date:
Have you submitted this information before?
Yes
No
If preferred, this form may be printed, filled out and mailed to:
ODOT Office of Civil Rights MS 23
3930 Fairview Industrial Drive SE
Salem, OR 97302-1166
Assistance is available upon request:
• Call toll-free (855) 540-6655
• E-mail ODOT_ADA@odot.state.or.us
• TTY, use 711 relay service, ask to connect to (855) 540-6655
734-5061 (9/2018)
Page 1 of 1
ODOT OFFICE OF CIVIL RIGHTS
COMMENT, QUESTION, CONCERN, OR REQUEST
Contact Information
NAME
DATE
ADDRESS
PHONE
CITY, STATE, ZIP
EMAIL
If you are completing this form on behalf of another person:
REPRESENTATIVE NAME
RELATIONSHIP
EMAIL
PHONE
Issue Description
LOCATION OF SITE – ADDRESS, SITE NAME, OR DESCRIPTION
TOPICS COVERED – CHECK ALL THAT APPLY
Curb ramp
Sidewalk
Parking
Service Animal
Transit Stop
Bathroom
Pushbuttons
Crosswalk
Audible Signal
DMV
Construction Work Zone
Other:
DESCRIPTION OF CONCERN, QUESTION, COMMENT OR REQUEST – INCLUDE THE DATE IF RELATED TO A SPECIFIC INCIDENT
Resolution
DESCRIBE THE RESOLUTION YOU WOULD LIKE TO SEE
If yes, date:
Have you submitted this information before?
Yes
No
If preferred, this form may be printed, filled out and mailed to:
ODOT Office of Civil Rights MS 23
3930 Fairview Industrial Drive SE
Salem, OR 97302-1166
Assistance is available upon request:
• Call toll-free (855) 540-6655
• E-mail ODOT_ADA@odot.state.or.us
• TTY, use 711 relay service, ask to connect to (855) 540-6655
734-5061 (9/2018)
Page 1 of 1