Form CEM-5773PW "Passageway Americans With Disabilities Act (Ada) Compliance Inspection Report" - California

What Is Form CEM-5773PW?

This is a legal form that was released by the California Department of Transportation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on November 1, 2017;
  • The latest edition provided by the California Department of Transportation;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CEM-5773PW by clicking the link below or browse more documents and templates provided by the California Department of Transportation.

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STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
PASSAGEWAY AMERICANS WITH DISABILITIES ACT (ADA) COMPLIANCE INSPECTION REPORT
CEM-5773PW (NEW 11/2017)
Page 1 of 8
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
County
City
Route
Route Name
Nearest Cross Street
PASSAGEWAY INFORMATION
Street Address
Construction Type
Passageway Type
New
A
Latitude (y)
Postmile/Station
Retrofit
B
C
Longitude (x)
Intersection Quadrant
Applicable Standard Plans
Applicable Standard Specifications
Northwest
2010 Standard Plan A88B
2010
Northeast
2010 Revised Standard Plan A88B Dated:
2015
Southwest
2015 Standard Plan A88B
Other
Southeast
2015 Revised Standard Plan A88B Dated:
Applicable Design Bulletin
Other
DIB 82-05
ADA PASSAGEWAY COMPLIANCE CERTIFICATION
Based on the field measurements shown on page 2, passageway Type A complies with standard plan A88B?
Yes
No
N/A
Based on the field measurements shown on page 3, passageway Type B complies with standard plan A88B?
Yes
No
N/A
Based on the field measurements shown on page 4, passageway Type C complies with standard plan A88B?
Yes
No
N/A
Passageway is ADA compliant based on ADA passageway check list shown on page 5?
Yes
No
Passageway is ADA compliant based on ADA passageway check list shown on page 6?
Yes
No
Passageway is ADA compliant based on ADA passageway check list shown on page 7?
Yes
No
This section must be completed if no is marked for any question indicating that a passageway is non-compliant.
District ADA engineer compliance determination (must state ADA standard used for compliance determination):
Passageway is compliant with ADA standards
Yes
No
District ADA Engineer (print name)
Signature
Date
RESIDENT ENGINEER ADA COMPLIANCE CERTIFICATION
I have reviewed the passageway inspection report and find that the constructed passageway 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
PASSAGEWAY AMERICANS WITH DISABILITIES ACT (ADA) COMPLIANCE INSPECTION REPORT
CEM-5773PW (NEW 11/2017)
Page 1 of 8
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
County
City
Route
Route Name
Nearest Cross Street
PASSAGEWAY INFORMATION
Street Address
Construction Type
Passageway Type
New
A
Latitude (y)
Postmile/Station
Retrofit
B
C
Longitude (x)
Intersection Quadrant
Applicable Standard Plans
Applicable Standard Specifications
Northwest
2010 Standard Plan A88B
2010
Northeast
2010 Revised Standard Plan A88B Dated:
2015
Southwest
2015 Standard Plan A88B
Other
Southeast
2015 Revised Standard Plan A88B Dated:
Applicable Design Bulletin
Other
DIB 82-05
ADA PASSAGEWAY COMPLIANCE CERTIFICATION
Based on the field measurements shown on page 2, passageway Type A complies with standard plan A88B?
Yes
No
N/A
Based on the field measurements shown on page 3, passageway Type B complies with standard plan A88B?
Yes
No
N/A
Based on the field measurements shown on page 4, passageway Type C complies with standard plan A88B?
Yes
No
N/A
Passageway is ADA compliant based on ADA passageway check list shown on page 5?
Yes
No
Passageway is ADA compliant based on ADA passageway check list shown on page 6?
Yes
No
Passageway is ADA compliant based on ADA passageway check list shown on page 7?
Yes
No
This section must be completed if no is marked for any question indicating that a passageway is non-compliant.
District ADA engineer compliance determination (must state ADA standard used for compliance determination):
Passageway is compliant with ADA standards
Yes
No
District ADA Engineer (print name)
Signature
Date
RESIDENT ENGINEER ADA COMPLIANCE CERTIFICATION
I have reviewed the passageway inspection report and find that the constructed passageway 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
PASSAGEWAY AMERICANS WITH DISABILITIES ACT (ADA) COMPLIANCE INSPECTION REPORT
CEM-5773PW (NEW 11/2017)
Page 2 of 8
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Northwest
Southwest
Nearest Cross Street
Northeast
Southeast
ADA PASSAGEWAY TYPE A FIELD MEASUREMENTS
Measure and verify the dimensions and slopes
Passageway
Passageway
Passageway
Passageway
Detectable Warning Surface
Detectable Warning Surface
Length
Slope
Cross Slope
Width
Width
Depth
(feet - inches)
(x.x%)
(x.x%)
(feet - inches)
(inches)
(inches)
L1
A1
D1
G1
M1
M2
P1
Q1
A2
D2
G2
N1
N2
P2
Q2
A3
D3
G3
1.7% or less?
1.7% or less?
49.75" or
Extends full width and less than 1"
24" min. for L > 6' - 0" to < 8' - 0"
Measured from
greater?
gap on either side?
36" min. for L ≥ 8' - 0"?
face of curb to
face of curb at
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
mid width along
path of travel.
Remarks
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
PASSAGEWAY AMERICANS WITH DISABILITIES ACT (ADA) COMPLIANCE INSPECTION REPORT
CEM-5773PW (NEW 11/2017)
Page 3 of 8
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Northwest
Southwest
Nearest Cross Street
Northeast
Southeast
ADA PASSAGEWAY TYPE B FIELD MEASUREMENTS
Measure and verify the dimensions and slopes
Passageway
Passageway
Passageway
Passageway
Detectable Warning Surface
Detectable Warning Surface
Length
Slope
Cross Slope
Width
Width
Depth
(feet - inches)
(x.x%)
(x.x%)
(feet - inches)
(inches)
(inches)
L
A1
D1
G1
M1
M2
P1
P2
A2
D2
G2
A3
D3
G3
B1
E1
H1
N1
N2
Q1
Q2
B2
E2
H2
B3
E3
H3
1.7% or less?
1.7% or less?
49.75" or
Extends full width and less than
24" min. for L > 6' - 0" to < 8' - 0"
Measured from
greater?
1" gap on either side?
36" min. for L ≥ 8' - 0"?
face of curb to
face of curb at
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
mid width along
path of travel.
Remarks
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
PASSAGEWAY AMERICANS WITH DISABILITIES ACT (ADA) COMPLIANCE INSPECTION REPORT
CEM-5773PW (NEW 11/2017)
Page 4 of 8
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Northwest
Southwest
Nearest Cross Street
Northeast
Southeast
ADA PASSAGEWAY TYPE C FIELD MEASUREMENTS
Measure and verify the dimensions and slopes
Passageway
Passageway
Passageway
Passageway
Detectable Warning Surface
Detectable Warning Surface
Length
Slope
Cross Slope
Width
Width
Depth
(feet - inches)
(x.x%)
(x.x%)
(feet - inches)
(inches)
(inches)
L1
A1
D1
G1
M1
M2
P1
P2
A2
D2
G2
A3
D3
G3
L2
B1
E1
H1
N1
N2
Q1
Q2
B2
E2
H2
B3
E3
H3
L3
C1
F1
I1
O1
O2
R1
R2
C2
F2
I2
C3
F3
I3
1.7% or less?
1.7% or less?
49.75" or
Extends full width and less than
24" min. for total L > 6' - 0" to < 8' - 0"
Measured from
greater?
1" gap or either sides?
36" min. for total L ≥ 8' - 0"?
face of curb to
face of curb at
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
mid width along
path of travel.
Remarks
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
PASSAGEWAY AMERICANS WITH DISABILITIES ACT (ADA) COMPLIANCE INSPECTION REPORT
CEM-5773PW (NEW 11/2017)
Page 5 of 8
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Northwest
Southwest
Nearest Cross Street
Northeast
Southeast
PASSAGEWAY FIELD INSPECTION CHECKLIST
No.
Requirement
Compliant
Photo
Remarks
Detectable warning surface was on the Authorized Material
Yes
No
List?
Detectable warning surface is yellow in color?
Yes
No
Yes
No
Yes
No
Detectable warning surface is in compliance with standard
Yes
No
Yes
No
Yes
No
plan A88A detail Raised Truncated Dome for dome diameter
and height?
Detectable warning surface is in compliance with standard
plan A88A detail Detectable Warning Surface for truncated
Yes
No
Yes
No
Yes
No
dome spacing?
Detectable warning surface edge nearest the street is
Yes
No
Yes
No
Yes
No
aligned with the face of curb? If yes, mark item 6 N/A.
Detectable warning surface edge nearest the street is
Yes
No
installed as shown on the project plans? Mark N/A if installed
Yes
No
Yes
No
N/A
per standard plan.
Detectable warning surface 5-year manufacturer's warranty
Yes
No
Yes
No
is on file?
Passageway surface has a broom finish, which provides slip
Yes
No
Yes
No
Yes
No
resistant surface?
Are all changes in surface level less than ¼”?
Yes
No
Yes
No
Yes
No
For any utility pull boxes, manholes, or vaults within the
boundary of passageway are they flush with the finished
Yes
No
Yes
No
Yes
No
surface? Mark item N/A if there are no utility pull boxes,
N/A
manholes, or vaults.
For openings or gratings located within the boundary of
passageway, are spaces less than ½” in one direction and
Yes
No
are elongated openings oriented perpendicular to dominate
Yes
No
Yes
No
N/A
direction of travel? Mark item N/A if there are no openings or
gratings.
For obstructions such as signposts, lighting standards,
power/telephone poles, guy-wires, or mail boxes in the
Item 13-16
N/A
construction area, complete items 13-16.
If no obstructions are located within the construction area,
mark items 13-16 N/A.
Are objects with leading edges between 27” to 80” height,
Yes
No
Yes
No
Yes
No
protected by guardrails or other barriers less than 27” above
N/A
the finished surface?
For objects with leading edges between 27” to 80” height, is
Yes
No
Yes
No
Yes
No
horizontal protrusion less than 4” (4.5” for handrails) without
N/A
reducing the 48” minimum clear width requirement?
For objects mounted on single posts that overhang the
Yes
No
Yes
No
Yes
No
passageway, are the overhangs less than 12” when located
N/A
between heights of 27” to 80”?
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.