Part I. Background Information:
Building/Program:

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
Others
(See notice at bottom of form). 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 “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 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 the "van" access aisles?
How wide are the other 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 and/or transit stop?
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 (Detectable Warnings) 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?
Do all inaccessible entrances have signs indicating the location of the nearest
accessible entrance?

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?
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?
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 public phones?
Is there a TTY in the building?
If water fountains are provided, what is the height of the spout from the floor?

f. Are rooms and spaces identified with raised, recessed or Braille numbers/words?

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 dispenser?
What is the height of the soap dispenser?
What is the measurement from 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?