Form CEM-5773SW "Sidewalk Americans With Disabities Act (Ada) Compliance Inspection Report" - California

What Is Form CEM-5773SW?

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Form Details:

  • Released on November 1, 2017;
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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
SIDEWALK AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 1 of 6
CEM-5773SW (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
SIDEWALK INFORMATION
Location Number
County
City
Route
Route Name
Begin Latitude (y)
Begin Longitude (x)
Begin Postmile/Station
Cross Street
End Latitude (y)
End Longitude (x)
End Postmile/Station
Segment Description
Begin Latitude (y)
Begin Longitude (x)
Begin Postmile/Station
Segment
No. 1
End Latitude (y)
End Longitude (x)
End Postmile/Station
Segment Description
Begin Latitude (y)
Begin Longitude (x)
Begin Postmile/Station
Segment
No. 2
End Latitude (y)
End Longitude (x)
End Postmile/Station
Segment Description
Begin Latitude (y)
Begin Longitude (x)
Begin Postmile/Station
Segment
No. 3
End Latitude (y)
End Longitude (x)
End Postmile/Station
Segment Description
Begin Latitude (y)
Begin Longitude (x)
Begin Postmile/Station
Segment
No. 4
End Latitude (y)
End Longitude (x)
End Postmile/Station
Segment Description
Begin Latitude (y)
Begin Longitude (x)
Begin Postmile/Station
Segment
No. 5
End Latitude (y)
End Longitude (x)
End Postmile/Station
Applicable Plans
Applicable Standard Specifications
Applicable Design Bulletin
Contract Plan Sheet
2010
Other
DIB 82-05
Other
2015
ADA SIDEWALK COMPLIANCE CERTIFICATION
Based on the field measurements shown on page 2 sidewalk complies with the contract plan sheet?
Yes
No
Sidewalk is ADA compliant based on ADA sidewalk check list shown on page 3?
Yes
No
Sidewalk is ADA compliant based on ADA sidewalk check list shown on page 4?
Yes
No
This section must be completed if no is marked for any question indicating that a sidewalk is non-compliant.
District ADA engineer compliance determination (must state ADA standard used for compliance determination):
Sidewalk is ADA compliant with ADA standards
Yes
No
District ADA Engineer (print name)
Signature
Date
RESIDENT ENGINEER ADA COMPLIANCE CERTIFICATION
I have reviewed the sidewalk inspection report and find that the constructed sidewalk is in compliance with ADA standards.
Resident Engineer (print name)
Signature
Date
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
SIDEWALK AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 1 of 6
CEM-5773SW (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
SIDEWALK INFORMATION
Location Number
County
City
Route
Route Name
Begin Latitude (y)
Begin Longitude (x)
Begin Postmile/Station
Cross Street
End Latitude (y)
End Longitude (x)
End Postmile/Station
Segment Description
Begin Latitude (y)
Begin Longitude (x)
Begin Postmile/Station
Segment
No. 1
End Latitude (y)
End Longitude (x)
End Postmile/Station
Segment Description
Begin Latitude (y)
Begin Longitude (x)
Begin Postmile/Station
Segment
No. 2
End Latitude (y)
End Longitude (x)
End Postmile/Station
Segment Description
Begin Latitude (y)
Begin Longitude (x)
Begin Postmile/Station
Segment
No. 3
End Latitude (y)
End Longitude (x)
End Postmile/Station
Segment Description
Begin Latitude (y)
Begin Longitude (x)
Begin Postmile/Station
Segment
No. 4
End Latitude (y)
End Longitude (x)
End Postmile/Station
Segment Description
Begin Latitude (y)
Begin Longitude (x)
Begin Postmile/Station
Segment
No. 5
End Latitude (y)
End Longitude (x)
End Postmile/Station
Applicable Plans
Applicable Standard Specifications
Applicable Design Bulletin
Contract Plan Sheet
2010
Other
DIB 82-05
Other
2015
ADA SIDEWALK COMPLIANCE CERTIFICATION
Based on the field measurements shown on page 2 sidewalk complies with the contract plan sheet?
Yes
No
Sidewalk is ADA compliant based on ADA sidewalk check list shown on page 3?
Yes
No
Sidewalk is ADA compliant based on ADA sidewalk check list shown on page 4?
Yes
No
This section must be completed if no is marked for any question indicating that a sidewalk is non-compliant.
District ADA engineer compliance determination (must state ADA standard used for compliance determination):
Sidewalk is ADA compliant with ADA standards
Yes
No
District ADA Engineer (print name)
Signature
Date
RESIDENT ENGINEER ADA COMPLIANCE CERTIFICATION
I have reviewed the sidewalk inspection report and find that the constructed sidewalk is in compliance with ADA standards.
Resident Engineer (print name)
Signature
Date
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
SIDEWALK AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
CEM-5773SW (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
County
City
Route
Route Name
Begin Latitude (y)
Begin Longitude (x)
Begin Postmile/Station
Cross Street
End Latitude (y)
End Longitude (x)
End Postmile/Station
SIDEWALK
Measure and field verify the dimensions and slopes shown
No.
Segment Description
Sidewalk Adjacent
Sidewalk Slope
Sidewalk Cross
Sidewalk Width
Photograph
Remarks
to Roadway?
(x.x%)
Slope (x.x%)
A1
B1
C1
A2
B2
C2
Yes
Yes
Yes
1
A3
B3
C3
No
No
No
A4
B4
C4
A5
B5
C5
A1
B1
C1
A2
B2
C2
Yes
Yes
Yes
2
A3
B3
C3
No
No
No
A4
B4
C4
A5
B5
C5
A1
B1
C1
A2
B2
C2
Yes
Yes
Yes
3
A3
B3
C3
No
No
No
A4
B4
C4
A5
B5
C5
A1
B1
C1
A2
B2
C2
Yes
Yes
Yes
4
A3
B3
C3
No
No
No
A4
B4
C4
A5
B5
C5
A1
B1
C1
A2
B2
C2
Yes
Yes
Yes
5
A3
B3
C3
No
No
No
A4
B4
C4
A5
B5
C5
Remarks
Roadway Grade (x.x%)
Non-adjacent
Adjacent
Sidewalk
Sidewalk
Sidewalk Slope
Sidewalk Slope
Cross Slope
Width
Note: Insert in the blanks ( ___ )
5.2% or less?
Slope does not
% or less?
inches or
provided the sidewalk slopes and
exceed roadway
greater?
dimensions shown in the contract
grade?
Yes
No
Yes
No
plans.
Yes
No
Yes
No
ADA standard
ADA standard
2.0% maximum
48" minimum
N/A
N/A
Inspection by (print name)
Signature
Date
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
SIDEWALK AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
CEM-5773SW (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
County
City
Route
Route Name
Begin Latitude (y)
Begin Longitude (x)
Begin Postmile/Station
Cross Street
End Latitude (y)
End Longitude (x)
End Postmile/Station
SIDEWALK ADA CHECKLIST
Compliant
No.
Requirement
Photo
Remarks
Segment
Segment
Segment
Segment
Segment
1
2
3
4
5
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Sidewalk surface has a broom finish, which provides slip resistant
1
surface?
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Are all changes in surface level less than ¼”?
2
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
For any utility pull boxes, manholes, or vaults within the boundary
No
No
No
No
No
3
of sidewalk, are they flush with the finished sidewalk surface?
No
No
N/A
N/A
N/A
N/A
N/A
Yes
Yes
Yes
Yes
Yes
For openings or gratings located within the boundary of sidewalk,
Yes
Yes
are spaces less than ½” in one direction and are elongated
No
No
No
No
No
4
No
No
openings oriented perpendicular to dominate direction of travel?
N/A
N/A
N/A
N/A
N/A
For obstructions such as signposts, lighting standards, power/
Item 6-9
Item 6-9
Item 6-9
Item 6-9
Item 6-9
Yes
Yes
telephone poles, guy-wires, or mail boxes in the driveway area,
5
N/A
N/A
N/A
N/A
N/A
No
No
complete items 6-9.
Yes
Yes
Yes
Yes
Yes
Are objects with leading edges between 27” to 80” height,
Yes
Yes
protected by guardrails or other barriers less than 27” above the
No
No
No
No
No
6
No
No
finished surface?
N/A
N/A
N/A
N/A
N/A
Yes
Yes
Yes
Yes
Yes
For objects with leading edges between 27” to 80” height, is
Yes
Yes
horizontal protrusion less than 4” (4.5” for handrails) without
No
No
No
No
No
7
No
No
reducing the 48” minimum clear width requirement?
N/A
N/A
N/A
N/A
N/A
Remarks
Field inspection checklist completed by (print name) Signature
Date
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
SIDEWALK AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
CEM-5773SW (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
County
City
Route
Route Name
Begin Latitude (y)
Begin Longitude (x)
Begin Postmile/Station
Cross Street
End Latitude (y)
End Longitude (x)
End Postmile/Station
SIDEWALK ADA CHECKLIST
Compliant
No.
Requirement
Photo
Remarks
Segment
Segment
Segment
Segment
Segment
1
2
3
4
5
Yes
Yes
Yes
Yes
Yes
For objects mounted on single posts that overhang the sidewalk
Yes
Yes
or curb ramp, are the overhangs less than 12” when located
No
No
No
No
No
8
No
No
between heights of 27” to 80”?
N/A
N/A
N/A
N/A
N/A
For objects mounted between posts where the clear distance
Yes
Yes
Yes
Yes
Yes
Yes
Yes
between posts is greater than 12”, is the lowest edge of such
No
No
No
No
No
9
object less than 27” or greater than 80” above the finished
No
No
N/A
N/A
N/A
N/A
N/A
surface?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Has backfill been placed against sidewalk or adjacent ground
10
leveled where sidewalk was constructed to prevent falling hazard?
No
No
No
No
No
No
No
Remarks
Field inspection checklist completed by (print name) Signature
Date
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
SIDEWALK AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 5 of 6
CEM-5773SW (REV 11/2017)
GENERAL INFORMATION
This form is to provide documentation necessary for project certification of sidewalks constructed to meet ADA requirements.
The Americans with Disabilities Act (ADA) of 1990, along with its implementing regulations, and the California Government Code
Sections 4450 et seq. prescribe that facilities shall be made accessible to persons with disabilities.
Design Information Bulletin 82, “Pedestrian Accessibility Guidelines for Highway Projects” (DIB 82), is Caltrans policy and contains
design requirements for Caltrans projects to comply with state codes, and federal laws and regulations regarding pedestrian
accessibility.
Contact the project engineer and district ADA engineer for additional information about ADA requirements and issues with sidewalk
compliance.
FORM
Complete the form for each sidewalk constructed on the project.
CONTRACT NUMBER/CO/RTE/PM: For local agency encroachment permit projects, write the encroachment permit number in the
CONTRACT NUMBER field.
PROJECT IDENTIFICATION NUMBER: For local agency encroachment permit projects, write N/A in the field.
Establish a location number for each sidewalk location.
For each sidewalk location provide:
County
City
Route
Route Name (e.g. State Route 49)
Name of the cross Street. For mid-block sidewalk, write N/A for cross street.
Identify locations for each sidewalk segment. Sidewalks must be broken down into segments to measure dimensions and slopes for
ADA compliance. Segments must not be more than 100 feet in length. Additional segments must be established based on curb ramps,
driveways, other interruptions in a continuous sidewalk and changes in sidewalk grade.
Latitude and longitude must be in decimal format to a minimum of six decimal places. Free GPS applications for smart phones, tablets,
and desk tops will report latitudes and longitudes to the necessary accuracy for differentiation of the permanent pedestrian facilities
locations.
Use applicable Design Bulletin: DIB 82-05 effective for projects ready to list 10/01/2013 or later.
Measure the dimensions and slopes shown on the form using measuring devices that meet the following standards:
For dimensional measurements, use a standard measuring tape with 1/8 inch minimum markings.
For slope measurements, use a smart level with a minimum sensor accuracy of 0.1 degrees.
Ensure that the smart level has been properly calibrated prior to taking measurements.
For measuring slopes on elements with dimensions 4 feet or less, use a 2-foot smart level. For measuring slopes on elements
with dimensions greater than 4 feet, use a 4-foot smart level.
Measurements taken must comply with the following:
Record dimensional measurements to the nearest 1/8 inch.
Record slope measurements to the nearest 0.1 percent.
For both dimensional and slope checks, take representative measurements equally dispersed across the surface in question.
Do not average the results. Record the individual measurements in the appropriate inspection report location.
Each sidewalk segment must be measured for compliance approximately 2 feet from each end and at the quarter points. For segments
less than 20 feet measure for compliance approximately 2 feet from each end and at the midpoint of the segment. Note in the remarks
the approximate length of short segments.
If any of the following occur, contact the project engineer and district ADA engineer:
Measured slope exceeds the allowable slope.
Measured dimension exceeds the allowable dimension.
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms
ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.
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