Community Services Programs

Americans with Disabilities Act Requirements; Summary of Inaccessible Features - Plan of Correction

Facility Name____________________________________ 

Address/Site Location _____________________________________

Work Sheet Completed by_____________________________ Telephone _______________

Date Completed ________________

Contact Person and Telephone #________________________________________________

Please Keep a copy of this form and plan of correction with your Licensing Material

 

Possible survey elements
(listed as reminders only)

Description of Barriers

Change Necessary

Cost Estimate &
Person Responsible

Implementation
Schedule

Date
Completed

Accessible Entrance Into Facility
Path of travel
Ramps
Parking
Drop off areas
Entrance Emergency Egress Signage
Other

     

2003           2004

 

Access to Programs
Horizontal Circulation
Doors
Rooms and Spaces
Signage
Controls
Seats,Tables and Counters
Vertical Circulation
Stairs
Elevators
Lifts

         

Access to Rest Rooms,
Getting to Rest Rooms..
Doorways and Passages
Stalls
Lavatories
Signage
Other

         

Other Elements
Drinking Elements
Telephones
Alarms
Other

         

 

Please return to: Licensing Specialist, Dept. of Developmental Services, Marquardt Building, 3rd Floor, 165 State House Station Augusta, ME 04333

 

Please complete this form only if you are unable to meet full ADA Compliance at your site within the next year.

PROGRAM ACCESS OPTIONS
Agency_______________________________ Site Location______________________

Address_______________________________________________________________

Worksheet completed by______________ Telephone _____________ Date_________

 

 

Location(s) where
Program Occurs

List significant barriers

Access option
S=structural
NS=Nonstructural

Detail nonstructural
Solutions (Use next
page for structural
solutions)

Schedule of
nonstructural changes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  

 

 

 

 

Copyright Adapative Environments Center. Product under contract to Barrier Free Environments, NIDRR grant #H133D10122<

Please complete this form only if you have structural barriers that you are unable to complete within the next year, or if
you are Claiming undue burden.

Agency___________________________ Total number of Sites _______________

This page completed by _______________________ Telephone _____________ Date____________

A) STRUCTURAL MODIFICATION TO BE COMPLETED (USE ADDITIONAL SHEETS IF NEEDED)

 

Facility

Description of Structural Changes

Cost
Estimate

Reason for Delay and anticipated completed date

 

 

 

 

 

 

 

 

 

 

 

B) MODIFICATION NOT TO BE IMPLEMENTED (USE ADDITIONAL SHEETS IF NECESSARY)

 

Facility

Description of Structural
Changes

Cost Estimate

Explanation of undue burden and
steps to be taken in lieu of barrier
removal

Date of Re-evaluation to determine if changes can now be made

  

 

 

   

 

 

 

 

 

 

 

 

Copyright Adapative Environments Center, Product under contract to Barrier Environments, NIDRR grant #1H133D10122