[AODA] Accessible Customer Service Feedback Process

[INSERT NAME OF YOUR ORGANIZATION] values its employees and customers, and strives to meet everyone’s needs. We are committed to providing quality goods and services that are accessible to all persons that we serve. All images are accessible, downloadable, and screen reader friendly. Feedback can be provided by phone, email, in person or by completing the form below.

Figure 1: Man's hand seen completing a customer feedback survey
Date * / MM / DD YYYY
Customer Service Contact First Last
Did we respond to your customer service needs today? *
Yes No
If no, please explain:
Scan Barcode
Did you have any problems accessing our goods or services? *
Yes No
If yes, please explain:
Scan Barcode
Please add any other comments or suggestions you may have:
Scan Barcode
Would you like to be contacted by the Accessibility Coordinator at [INSERT NAME OF YOUR ORGANIZATION] in response to your feedback?
Yes No
If yes, please ensure you provide us with your contact information below:

Any personal information is collected pursuant to AODA Ontario Regulation 429/07, the Accessible Standards for Customer Service, and will be used strictly for the purpose of responding to your feedback
Your Name First Last
Email Address
Scan Barcode

Confirm Email *
Address
Address Type Street Address Address Line 2 Apartment City State / Province / Region Postal / Zip Code Country
Telephone - ### - ### ####
How would you like to be contacted?
In person Telephone Email Mail
Preferred date of visit or call? / MM / DD YYYY
Preferred time of visit or call? : HH MM AM/PM
Alternate document formats, communication supports and service accommodations are available upon request in order to effectively receive and respond to your feedback. Please indicate if you require any special accommodations in order to communicate with or serve you in a manner that takes your disability into account.

Yes No
If yes, please explain
Scan Barcode
Your customer service experience is important to us. Thank you for taking the time to provide us with your feedback.

If requested above, customers will be contacted within [ENTER NUMBER] business days after submission of this form.

Incorrect password

Forgot Password?

[AODA] Accessible Customer Service Feedback Process

[AODA] Accessible Customer Service Feedback Process

If yes, please ensure you provide us with your contact information below:

Your customer service experience is important to us. Thank you for taking the time to provide us with your feedback.