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Checklist and Score Sheet |
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Version 3 |
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Site: |
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Date: |
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| Building: |
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| Purpose: |
Level or Ramped Access
Dormatory |
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| Approach: |
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Disabled Parking: |
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Van Access: |
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Accessible Route - ck: |
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Building Access |
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Inside |
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Bathroom |
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Steps |
Lift |
Ramp |
Level Access |
Power Doors |
Elevator/1 level |
AC |
High Toilet |
Grab Bars |
30" Side |
Score |
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| Weight: |
0 |
2 |
4 |
8 |
5 |
5 |
2 |
2 |
1 |
2 |
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| Score: |
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| Detail: |
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No. of Steps: |
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Number of Floors: |
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| Notes: |
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| Building: |
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| Purpose: |
Dining Hall - Food |
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| Approach: |
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Disabled Parking: |
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Van Access: |
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Accessible Route - ck: |
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Building Access |
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Inside |
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Bathroom |
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Steps |
Lift |
Ramp |
Level Access |
Power Doors |
Elevator/1 level |
AC |
High Toilet |
Grab Bars |
30" Side |
Score |
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| Weight: |
0 |
2 |
4 |
8 |
5 |
5 |
2 |
2 |
1 |
2 |
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| Score: |
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| Detail: |
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No. of Steps: |
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Number of Floors: |
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| Notes: |
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| Building: |
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| Purpose: |
Large Meeting Location |
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| Approach: |
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Disabled Parking: |
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Van Access: |
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Accessible Route - ck: |
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Building Access |
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Inside |
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Bathroom |
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Steps |
Lift |
Ramp |
Level Access |
Power Doors |
Elevator/1 level |
AC |
High Toilet |
Grab Bars |
30" Side |
Score |
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| Weight: |
0 |
2 |
4 |
8 |
5 |
5 |
2 |
2 |
1 |
2 |
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| Score: |
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| Detail: |
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No. of Steps: |
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Number of Floors: |
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| Notes: |
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| Building: |
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| Purpose: |
Smaller Break out Rooms |
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| Approach: |
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Disabled Parking: |
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Van Access: |
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Accessible Route - ck: |
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Building Access |
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Inside |
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Bathroom |
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Steps |
Lift |
Ramp |
Level Access |
Power Doors |
Elevator/1 level |
AC |
High Toilet |
Grab Bars |
30" Side |
Score |
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| Weight: |
0 |
2 |
4 |
8 |
5 |
5 |
2 |
2 |
1 |
2 |
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| Score: |
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| Detail: |
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No. of Steps: |
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Number of Floors: |
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| Notes: |
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| Building: |
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| Purpose: |
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| Approach: |
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Disabled Parking: |
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Van Access: |
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Accessible Route - ck: |
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Building Access |
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Inside |
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Bathroom |
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Steps |
Lift |
Ramp |
Level Access |
Power Doors |
Elevator/1 level |
AC |
High Toilet |
Grab Bars |
30" Side |
Score |
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| Weight: |
0 |
2 |
4 |
8 |
5 |
5 |
2 |
2 |
1 |
2 |
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| Score: |
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| Detail: |
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No. of Steps: |
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Number of Floors: |
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| Notes: |
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| Building: |
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| Purpose: |
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| Approach: |
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Disabled Parking: |
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Van Access: |
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Accessible Route - ck: |
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Building Access |
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Inside |
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Bathroom |
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Steps |
Lift |
Ramp |
Level Access |
Power Doors |
Elevator/1 level |
AC |
High Toilet |
Grab Bars |
30" Side |
Score |
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| Weight: |
0 |
2 |
4 |
8 |
5 |
5 |
2 |
2 |
1 |
2 |
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| Score: |
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| Detail: |
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No. of Steps: |
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Number of Floors: |
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| Notes: |
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| Additional
Points/Information: |
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Hearing Assistive Devices
for Large Meetings |
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10 |
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Wheel Chair Access to
Stage/Platform |
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10 |
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Motel within Walking
Distance (2 blocks) |
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5 |
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Distances --- Measure with wheel using the accessible
route - no steps. |
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Actual Distance in Feet |
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Feet |
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Miles |
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Accessible Dorm to Dining
Hall |
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Dining Hall to Large Meeting |
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Accessible Dorm to Large
Meeting |
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Dining Hall to Break out
rooms |
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Tent Camping to Dining or
Large Meeting |
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Pick shortest of two |
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RV Camping to Dining or
Large Meeting |
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Pick shortest of two |
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Golf Cart Shuttle (Full
Size or VW Van doesn't count -- too high) |
10 |
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Tent Camping |
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5 |
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RV Dry Camping |
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2 |
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Rv AC Power for medical
needs. -- add 5 points |
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5 |
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Other Positive Access
Items: |
(write in and assign points and explain in detail on the
back) |
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Additional Score |
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| Legend
- Detailed Description of survey items. |
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| Approach: |
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Disabled Parking: |
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Van Access: |
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Accessible Route - ck: |
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Disabled Parking: |
Enter the number of
disabled parking spots associated with the building, 0 if none. |
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Van Access: |
Enter the number of van
accessible disabled parking spots associated with the building, 0 if none. |
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Accessible Route - ck: |
Check of if route is
direct and has curb cuts. Add more
details in Notes field. |
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Building Access |
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Inside |
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Bathroom |
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Steps |
Lift |
Ramp |
Level Access |
Power Doors |
Elevator/1 level |
AC |
High Toilet |
Grab Bars |
30" Side |
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| Weight: |
1 |
2 |
4 |
8 |
5 |
5 |
2 |
2 |
1 |
2 |
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| Building
Access |
These items deal with
entering the building from the outside. |
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Note: Enter only the best one of Steps, Lift,
Ramp, Elevator or Level Access. |
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Steps |
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Enter this item if the
only way into the building is by climbing steps. Enter the number of steps below the line. |
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Note: If not level access, be sure to enter the
number of steps below. |
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Lift |
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Enter this item the
building has a platform wheel chair lift.
Note: Must be ADAAG approved as follows: |
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ADAAG Standards for
platform lifts. |
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Note: Incline lifts or
stair seats are not acceptable. |
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Ramp |
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Enter this item if a ramp
is available for wheel chair access.
Must meet ADAAG standards as follows: |
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Slope: 1 inch per 16 inches desired, 1 inch per
foot maximum slope. |
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Resting Places: Every 10 feet requires a level resting
place without slope. |
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Hand Railing: Required |
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Width: |
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Level Access |
Enter this item if the
building has level access. Note
threshold heights if more than 1/4 inch. |
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Power Doors |
Bonus item -- enter this
item as a bonus since this makes access much easier. |
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| Inside
Building |
These items deal with the
inside of the building and moving between floors and for comfort on hot days. |
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Elevator/ |
Enter
this item if a commercial elevator is provided to go between floors or every
room is on 1 level. Platform lifts
are not sufficient |
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1 Level |
Platform lifts are not sufficient - but
note on form. |
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AC |
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Air conditioning. Enter
if available -- important to some who are heat sensitive and all for comfort. |
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| Bathroom |
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These items deal with the
accessible bathroom(s) in the building.
If the main bathrooms are not accessible look |
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for a special uni-sex
accessible bathroom. Both the men's
and the woman's restrooms must be accessible |
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High Toilet |
Enter this item if the
toilet is 17-19 inches tall. MEASURE
since the exact height is important. |
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Grab Bars |
Enter this item if there
are ADAAG standard Grab Bars on the wall beside the toilet and behind the
toilet. |
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30" Side |
Enter this item if the
toilet meets the ADAAG standards for side transfer. MEASURE since the exact space is important. |
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Side
Transfer means to back the wheel chair parallel to the toilet and then slide
sideways from the chair onto and off |
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of the toilet. Measure from the side of the toilet seat
to the furthest wall for 30" or more. |
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The minimum standard for
stalls is 5 ft square. |
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