ADA
ACCESS SURVEY FORM

**Part I. Background Information:**

Agency _______________________________________________________________________

Building Location ______________________________________________________________

State Owned ___ Leased ___ Rented ___

Person(s) completing the survey _____________________________________________

(phone) ____________________________________________________

Date Completed ___________________________________

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? ____ If these are in a parking lot, how many total parking spaces are available? ____ Are each 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 aisles? ____________

c. Do handicapped 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 tot he 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? _____

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? ________ Is there a handrail on at least one side 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 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 they swing? ______ Is the handle of a lever or loop type? __________

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? ______

h. What pressure pull is required to open the primary entrance door? __________ (NOTE: an easy tool to measure this is a fishing scale)

i. 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? __________ Is a handrail installed on at least one side 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 phones? ____________ If water fountains are provided, what is the height of the spout? _____________

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? __________ How far away from the wall is it

located? ___________

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 height of the lower edge of the mirror? ________ 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? ___________