Page 1 of 5

All fields below are required unless otherwise indicated.

Enter a valid license
Enter a valid ID
Enter a valid ID
Select a specialty
Enter a valid name
Enter a valid name
Enter a valid address
Enter a valid address
Enter a valid city
Enter a valid state
Enter a valid zip

Do you see patients at the address listed above? If not (e.g., you’re an inpatient provider only or administrative only) please indicate so by selecting No.

Select a response
Page 1 of 5
Page 2 of 5

Access to Facility from the Exterior Continued

All fields below are required unless otherwise indicated.

7. Does the main exterior entrance door used by persons with mobility disabilities to access public spaces meet the following standards:

a) 32 inches clear opening.

Select a response

b) 18 inches of clear wall space on the pull side of the door, next to the handle.

Select a response

c) The threshold edge is no greater than ¼ inch high or if beveled, no greater than ¾ inches high.

Select a response

d) The door handle is no higher than 48 inches high and can be operated with a closed fist.

Select a response

8. a.) Are there ramps to permit wheelchair access?

Select a response

b) Are the slopes of the ramp accessible for wheelchair access?

Select a response

c) Are the railings sturdy and high enough for wheelchair access?

Select a response

d) Is the width between railings wide enough to accommodate a wheelchair?

Select a response

e) Are the ramps nonslip and free from any obstruction (cracks)?

Select a response

9.If there are stairs at the main entrance, is there also a ramp or lift or is there an alternative accessible entrance?

Select a response

10.Do any inaccessible entrances have signs indicating the location of the nearest accessible entrance?

Select a response

11.Can the accessible entrance be used independently and without assistance?

Select a response

12.Are doormats ½ inch high or less with beveled or secured edges?

Select a response
Page 2 of 5
Page 3 of 5

Access to Interior Spaces

All fields below are required unless otherwise indicated.

13. Are waiting rooms and exam rooms accessible to people with disabilities?

Select a response

14.The layout of the interior of the building allows people with disabilities to obtain materials and services without assistance.

Select a response

15. Do the interior doors used by persons with mobility disabilities to access public spaces meet the following standards:

a) 32 inches clear opening.

Select a response

b) 18 inches of clear wall space on the pull side of the door, next to the handle.

Select a response

c) The threshold edge is no greater than ¼ inch high or if beveled, no greater than ¾ inches high.

Select a response

d) The door handle is no higher than 48 inches high and can be operated with a closed fist.

Select a response

16. The accessible routes to all public spaces in the facility are 31 inches wide.

Select a response

17. There is a 5 foot circle or a T-shaped space for a disabled person using a wheelchair to reverse direction in public areas where services are rendered.

Select a response

18. All buttons or other controls in the hallway are no higher than 42 inches.

Select a response

19. Elevators in the facility meet the following standards:

a) There are raised and Braille signs on both door jambs on every floor.

Select a response

b) The call buttons in the hallway are not higher than 42 inches.

Select a response

c) The controls inside the cab have raised and Braille lettering.

Select a response

20. Are sign language interpreters and other auxiliary aids and services provided in appropriate circumstances?

Select a response
Page 3 of 5
Page 4 of 5

Access to Public Lavatory

All fields below are required unless otherwise indicated.

21.Is the public lavatory wheelchair-accessible?

Select a response

22.With respect to the public restroom, the accessible route, the exterior door and the interior stall doors comply with standards set forth above for exterior doors.

Select a response

23.There is at least one wheelchair accessible stall in the public restroom that has an area of at least 5 feet by 5 feet, clear of the door swing; OR there is at least one stall that is less accessible but that provides greater access than a typical stall (either 36 by 69 inches, or 48 by 69 inches).

Select a response

24.In the accessible stall of the public rest room there are grab bars behind and on the side wall nearest the toilet.

Select a response

25.There is one lavatory in the public restroom that meets the following standards:

a) 30 inches wide by 48 inches; deep bar space in front.

Select a response

b) A maximum of 19 inches of the required depth may be under the lavatory.

Select a response

c) The lavatory rim is no higher than 34 inches.

Select a response

d) There is at least 29 inches from the floor to the bottom of the lavatory apron.

Select a response

e) The soap dispenser and hand dryers are within reach and usable with one closed fist.

Select a response

f) The faucet can be operated with a closed fist.

Select a response

g) The mirror is mounted with the bottom edge of the reflecting surface 40 inches from the floor or lower.

Select a response
Page 4 of 5
Page 5 of 5

Because you have indicated that you do not see patients at the above listed address, the American with Disabilities Act Attestion Form questions are not applicable to you.

Please electronically sign this form and submit it.

Electronic Signature

I hereby attest that we are a provider that has a physical site at which Participants might possibly be physically present and that the answers provided are accurate. Also, I do hereby attest that I hold the authority to make these attestations.

Enter a valid provider name
Enter a valid date
Page 5 of 5