Site Survey Request Form

Thank you for your request for a site accessibility survey with the Northwest ADA Center. In order to organize a scope of work and be able to address your needs as soon as possible, we would appreciate it if you could answer some questions to give us a few details about you and your request.

Name *

Position

Name of Organization *

Email *

Phone *

Cell Phone *

Address:

Date of Request *

Month

Day

Year

Features to Survey (select all that apply) *

Parking (Accessible parking space(s), path of travel

Sidewalk, path to the main entrance of the building(s), Reception areas, entry doors, path of travel)

Rooms (e.g. conference room(s), break room, food/cafeteria places, etc.)

Restrooms - accessible stall(s) (e.g. counter, sink, mirror, plumbing, toilets, flush control, doors, path of travel, measurements and pressure etc.)

Exits Doors or Egress (signage, landing, area of refuge, etc.)

Other elements (exhibit areas, library, gift shop, etc.)

Estimated Square Footage to Survey (if known)

What is your estimated budget? *

Please enter your estimated budget. If you are unsure at this time, please put TBD.

Level of Report Needed (select one) *

No written report needed; just a walk-through survey.

A general summary and recommendations with the most concerns (prioritizing the elements of concerns) for improving access to the buildings/areas related to public access.

A report that identifies every building element that does not meet the ADA Accessible Design Standards (refer above list) and provides photos or evidence of each elements that are out of compliance.

What is your time frame for accomplishing this project? *

Month

Day

Year