Part I. Background Information:
Building/Program:___________________________________________________________ Address:___________________________________________________________________
Person(s) completing the survey _____________________________________________
Address & Phone/e-mail ______________________________________________
Date Completed ___________________________________
Type of Program or Function (check at least one): Government ____ Business ____ Restaurant ____ Medical ____ Hotel/Motel ____ Library ____ Educational ____ Others ____
Some questions may not apply. Please designate N/A in that instance. Attach additional sheets as needed for any explanations.
Part II. Parking:
a. How many persons with disabilities parking spaces are available? ____ Is at least one parking space designated as van accessible? ____ Is it on-street parking? ____ Or in a parking lot? ____ If these are in a parking lot, how many total parking spaces are available? ____ Are each accessible parking spaces identified with an upright sign? ____ Where is the designated parking in relationship to the primary entrance? _______________________________________________
b. Are access aisles adjacent to the persons with disabilities parking spaces? ____ How wide are the parking spaces? __________ How wide are the van access aisles? ______ How wide are other access aisles?_____
c. Do persons with disabilities parking spaces allow people to get in or out on a level surface? ____
d. Does the individual using the persons with disabilities parking space have to navigate behind parked cars to gain entrance to the building? ______
Part III. Sidewalks:
a. How wide are the public sidewalks? _______ Are they level? _______ If not, do they slope away from the building, toward the building, or along the length of the walk? ________________________________
b. Is there at least one sidewalk with no steps leading to the primary entrance? ____ Does the sidewalk connect to the persons with disabilities parking area? ____ Is there a curb cut at the end of the sidewalk? ____ If so, how high is the curb? _____ and how long is the curb cut or sloped portion of the sidewalk? _____ Is the curb cut surface a different texture than the sidewalk or have detectable warning inserts? _____
c. Are walks of a continuing common surface and not interrupted by steps or abrupt changes in
level? _____
d. Do walks have a level platform at the door which is at least 5 feet by 5 feet? __________ If not, what is the size of the level platform? ________________ Does the door swing in or out? ______________
Part III. Entrances/Exits:
a. Is at least one primary entrance to the building on ground level or with a ramped approach? _______ How many floors/levels does this building have? ___________ If more than one, is the entrance on the same level as access to the elevator? __________
b. If more than one floor, can access be gained to all meeting rooms, offices, and common areas from the elevator? __________ At what height are the elevator controls? (top and bottom) _____________ Are the buttons labeled with raised or indented letters? __________ What are the inside dimensions of the elevator? _____________________
c. If a ramp is used, what is the height of the rise it serves? __________ What is the length of the ramp? ________ Are there handrails on both sides of the ramp? _________ Is this ramp of permanent construction? __________
d. Is the primary entrance unlocked at all times? __________
e. What is the width
of the primary entrance door? _______________ If double doors, what is the
width of each door? __________ Are there doors in a series at the entrance?
___________ If so, how far apart are the doors? _____ Which way do the doors
swing? ______ Is the handle of a lever or loop type? __________ Do all inaccessible entrances have signs
f. Is the height of the threshold ½ or less? __________
g. Does the primary entrance contain a revolving door or turnstile? ______ If so, is there a usable door at the same location? ______ Is there an accessible route provided through fixed security barriers at required accessible entrance(s)? _________
h. Is there a primary entrance with an automatic door opener? ______ If not, what pressure pull is required to open the primary entrance door? __________ (NOTE: an easy tool to measure this is a fishing scale)
i. If two-way communication is required to gain admittance to the facility or restricted area(s) within the facility, does the system provide both visual and audible signals? _____
j. Is the symbol of accessibility used to designate barrier free entrance? ______
Part IV. Interior Circulation:
a. Do all doors have a clear opening of at least 32 when open? __________ Do all doors operate with a single effort? __________ What pull/push weight is required to operate doors? ___________ Do the doors have lever or loop type handles? __________
b. Is the floor on the inside and outside of each doorway level for a distance of 5 feet from the door in the direction the door swings? __________ Does the flat surface extend 15 to 18 on each side of the door? __________
c. Does any interior doorway have a threshold over ½? __________
d. If interior ramps are used, what is the height of the rise? __________ What is the length of the
ramp? __________ Are there handrails installed on both sides of the ramp? __________ Does the ramp have a non-slip surface? ______ What is the height of the handrail? ______ Do the handrails extend 1 foot beyond each end of the ramp? ______
e. What is the height of the public phones? ____________ Is there a working TTY in the building? ____ If water fountains are provided, what is the height of the spout from the floor? _____________
f. Are raised, recessed or Braille numbers/words provided on rooms? __________
g. Are there fire extinguishers, plants, other obstacles protruding from the wall that do not reach the floor? If so, how far do they protrude? __________
Part V. Restrooms:
a. Are there toilet rooms and/or stalls designed to be accessible? __________ Are there any steps or obstructions leading to the toilet rooms? ___________ What is the clear opening width of the entrance door? __________ Are there doors in a series? __________ If so, how far apart are they? __________ If a 90-degree turn is required in the entrance, what is the corridor width? __________ What pressure pull is required to open the door(s)? __________
b. Is there at least one place in the toilet room that provides a full 5 foot diameter open floor space?_____ How wide is the area between the wall and the front of the stalls? __________ If stalls are provided, what are the dimensions of the largest compartment? ___________________ Does the door on the compartment swing out? _____ What is the open width of the door? __________ Are grab bars provided? _____ If so, at what height are they mounted? __________ How many grab bars are in the compartment? ___________ Are they located on the side or behind the stool? __________ What is the diameter of the grab bar? __________ What is the width of the space between the wall and grab bar? ___________
c. What is the height of the stool? _____ What is the height of the urinal? __________ Are there grab bars at the urinal? ________ What is the height of the towel or towel dispense? ________ What is the height of the soap dispenser? ________ What is the measurement from the bottom edge of the reflecting surface of the mirror to the floor? ________ What is the measurement from the lower edge of the lavatory to the floor? ________ Are dispensers located at the side of or above the lavatory? ________
d. Do appropriate signs identify accessible toilet facilities? __________ Are the handles of the faucets single handle or blade type? __________ Are the drain and hot water pipes wrapped? __________
Part VI. Other:
a. Are switches and controls for light, heat, ventilation, window draperies, fire alarms and all similar controls of frequent or essential use within 54 of the floor? ___________ and higher than 18 from the floor? ___________
b. Are audible warning signals accompanied by simultaneous visual signals? __________
c. Are there low-hanging door closures that remain within the opening of a doorway or that protrude into regular corridors or traffic ways? __________ If so, at what height? __________
d. Are there low hanging signs, ceiling lights, fans, fixtures, or similar objects that protrude into regular corridors or traffic ways? __________ If so, at what height? ___________