The Commonwealth of Massachusetts
Department of Public Safety
Architectural Access Board
One Ashburton Place, Room 1310
Boston Massachusetts 02108-1618
Phone: 617-727-0660
Fax: 617-727-0665
www.mass.gov/dps





Docket Number


____________
(Office Use Only)


TELEPHONE COMPLAINT FORM
Section 37, 521 CMR


PLEASE BE ADVISED THAT THIS FORM IS A MATTER OF PUBLIC RECORD AND WILL BE DISCLOSED UPON REQUEST.

1.	Exact location of the public telephone (i.e. 1st floor lobby of building at 12 Main Street, or northeast corner of Broadway and Main Street, or other landmarks):
	Location:______________________________________________________________
	Address:______________________________________________________________
	City/Town:______________________________________________________________


2.	Please check which telephone company name is imprinted on the phone:
	Verizon _____	AT & T ______	 Sprint ______
	Other (please specify): ____________________________________________________


3.	Phone number of the above phone: __________________________________________


4.	How many public telephones are provided at the above location? ___________________


5.	Public telephones were installed _____ before or _____ after September 1, 1996.


6.	Check the following items which you believe are in violation:

____	Clear Floor Space of 30 inches by 48 inches is not provided at accessible telephones. (Section 37.2)

____	Kneespace is less than 30 inches wide and 30 inches high for forward approach only. (Section 37.2.1)

____	The highest operable part of the telephone, including dial, handset and coin deposit slots, is not within the Forward Reach (between 15 inches and 48 inches, See Section 6.5), or Side Reach (between 9 inches and 54 inches, See Section 6.6). (Section 37.3)

____	Accessible telephone is not located on an accessible route. (Section 37.4)

____	Telephone is not hearing-aid compatible.  (Section 37.5)
	
____	Volume control is not provided. (37.5.1)

____	Instructions for use of volume control are not attached to or next to the telephone. (Section 37.5.2)

____	Telephone does not have push button controls where service for such equipment is available. (Section 37.6)
	
____	Telephone book, if provided, is not located in a position that complies with the Forward Reach (Section 6.5) and Side Reach (Section 6.6). (Section 37.7) 

____	Two or more telephones are provided in the same location and one is not equipped with a TTY. (Section 37.8)

____	Telephone cord is not at least 29 inches long to allow connection of the TTY to the telephone receiver when an acoustic coupler is provided. (Section 37.8)

____	A single interior public payphone is provided in a stadium or arena, a convention center, a hotel with a convention center, a covered mall, a public use area of a governmental building, in or adjacent to a hospital emergency room, or in a recovery room or hospital waiting room, and it is not equipped with a TTY. (Section 37.8)

____	Three or more pay telephones are provided in a bank, and one is not equipped with a shelf and an electrical outlet within or adjacent to the telephone enclosure for portable TTY. (Section 37.9)

____	Telephone handset is not capable of being placed flush on the surface of the shelf.  The shelf is not at least 9 inches wide by 12 inches deep and does not have 6 inches minimum of vertical clearance. (Section 37.9)

____	International TTY symbol and directional signage is not provided on TTY. (Section 37.10.1)

____	Signage for hearing amplified telephone is not identified with signage. (Section 37.10)
	
	____	Other (please specify):__________________________________________________


7.	Name of the management company that is responsible for the building (if known): __________________________________________________________________________________________________________________________________________________


8.	Do you want to receive copies of all correspondence regarding the complaint and be notified of any meetings or hearings? ____ yes	____no


9.	Name and address of person/organization filing this complaint (if organization is filing, please provide the Board with the name of a contact person) (required):_______________
	_________________________________________________________________________
	E-mail:___________________________________________________________________
	Telephone: _______________________________________________________________
	

10.	Individual Signature (required):________________________________________________
	Date: ____________________
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