Guide Dog owner access questionnaire

Name of town or city:

Has the local authority made provision for deaf, blind and disabled people with assistance dogs by encouraging local businesses to clearly display an 'Assistance Dogs welcome' sticker?

From your own experience, please assess each of the following facilities in this town/city and put a tick in the column which clearly describes the service each one offers you with your assistance dog. NB: leave blank any you don't know

To nominate an individual business or service provider, please complete Section B. If not, please go straight to Section C.

Name of business or service provider:

Address of business or service provider:

Contact person and phone number (if known):

Buisness email address (if known):

Each business or service provider will be judged on its deaf/blind/disabled awareness, acceptance of assistance dogs and willingness to offer assistance dog partnerships equal access to its amenities - or to make reasonable adjustments if necessary. If you can, please assess the performance of the business or service provider in the following. NB: leave blank any you don't know.

NB: Sections marked with an * must be completed.

Please explain the reasons for your nominations *.

Please give your details

Full name *:

Address *:

Telephone number *:

Email address *:

Please indicate which applies to you. I am:

Your assistance dog's name:

Which Assistance Dogs charity are you registered with?

Assistance Dogs UK will send an access questionnaire to each town, city, business or service provider you have nominated. If they can fulfil the access requirements of all assistance dog users they will be awarded a Dog Star award in 2008. We will contact you again if your nomination is successful, inviting you to present the award and participate in publicity.

For any further information about the nomination process or the awards themselves, please contact vicky.bell@guidedogs.org.uk