Form CEM-5773B "Curb Ramp (Case B) Americans With Disabilities Act (Ada) Compliance Inspection Report" - California

What Is Form CEM-5773B?

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;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

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

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Download Form CEM-5773B "Curb Ramp (Case B) Americans With Disabilities Act (Ada) Compliance Inspection Report" - California

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CURB RAMP (CASE B) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 1 of 10
CEM-5773B (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
CURB RAMP INFORMATION
Location Number
County
City
Route
Route Name
Cross Street
Latitude (y)
Postmile/Station
Intersection Control
Construction Type
Ramp
None
New
Single
Longitude (x)
Street Grade (%)
Stop/Yield
Retrofit
Dual Ramp 1
Signalized
Dual Ramp 2
Intersection Quadrant
Applicable Standard Plans
Applicable Standard Specifications
Northwest
2010 Standard Plan A88A
2010
Northeast
2010 Revised Standard Plan A88A Dated:
2015
Southwest
2015 Standard Plan A88A
Other
Southeast
2015 Revised Standard Plan A88A Dated:
Applicable Design Bulletin
Mid-Block
Other
DIB 82-05
ADA CURB RAMP COMPLIANCE CERTIFICATION
Based on the field measurements shown on page 2 curb ramp complies with standard plan A88A?
Yes
No
Based on the field measurements shown on page 3 curb ramp complies with standard plan A88A?
Yes
No
Based on the field measurements shown on page 4 curb ramp complies with standard plan A88A?
Yes
No
Based on the field measurements shown on page 5 curb ramp complies with standard plan A88A?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 6?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 7?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 8?
Yes
No
This section must be completed if no is marked for any question indicating that a curb ramp is non-compliant.
District ADA engineer compliance determination (must state ADA standard used for compliance determination):
Curb ramp is ADA compliant with ADA standards
Yes
No
District ADA Engineer (print name)
Signature
Date
RESIDENT ENGINEER ADA COMPLIANCE CERTIFICATION
I have reviewed the curb ramp inspection report and find that the constructed curb ramp 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.
CURB RAMP (CASE B) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 1 of 10
CEM-5773B (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
CURB RAMP INFORMATION
Location Number
County
City
Route
Route Name
Cross Street
Latitude (y)
Postmile/Station
Intersection Control
Construction Type
Ramp
None
New
Single
Longitude (x)
Street Grade (%)
Stop/Yield
Retrofit
Dual Ramp 1
Signalized
Dual Ramp 2
Intersection Quadrant
Applicable Standard Plans
Applicable Standard Specifications
Northwest
2010 Standard Plan A88A
2010
Northeast
2010 Revised Standard Plan A88A Dated:
2015
Southwest
2015 Standard Plan A88A
Other
Southeast
2015 Revised Standard Plan A88A Dated:
Applicable Design Bulletin
Mid-Block
Other
DIB 82-05
ADA CURB RAMP COMPLIANCE CERTIFICATION
Based on the field measurements shown on page 2 curb ramp complies with standard plan A88A?
Yes
No
Based on the field measurements shown on page 3 curb ramp complies with standard plan A88A?
Yes
No
Based on the field measurements shown on page 4 curb ramp complies with standard plan A88A?
Yes
No
Based on the field measurements shown on page 5 curb ramp complies with standard plan A88A?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 6?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 7?
Yes
No
Curb ramp is ADA compliant based on ADA curb ramp check list shown on page 8?
Yes
No
This section must be completed if no is marked for any question indicating that a curb ramp is non-compliant.
District ADA engineer compliance determination (must state ADA standard used for compliance determination):
Curb ramp is ADA compliant with ADA standards
Yes
No
District ADA Engineer (print name)
Signature
Date
RESIDENT ENGINEER ADA COMPLIANCE CERTIFICATION
I have reviewed the curb ramp inspection report and find that the constructed curb ramp 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.
CURB RAMP (CASE B) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 2 of 10
CEM-5773B (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Passageway Type
Northwest
Southwest
Single
Cross Street
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (CASE B) FIELD MEASUREMENTS
Measure and verify the dimensions and slopes:
Ramp
Ramp
Ramp
Left Flare
Right Flare
Gutter
Gutter
Road Surface
Slope
Cross Slope
Width
Slope at Back
Slope at Back
Slope
Cross Slope
Cross Slope
(x.x%)
(x.x%)
(inches)
of Curb
of Curb
(x.x%)
(x.x%)
within 2'
(x.x%)
(x.x%)
from Ramp
(x.x%)
A1
B1
C1
D1
E1
F1
G1
H1
A2
B2
C2
F2
G2
H2
A3
B3
C3
G3
H3
7.7% or less?
1.7% or less?
59.75" or
9.2% or less?
9.2% or less?
1.7% or less?
4.4% or less?
5.2% or less?
greater?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
N/A
Gutter is 24" or
more wide.
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.
CURB RAMP (CASE B) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 3 of 10
CEM-5773B (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Passageway Type
Northwest
Southwest
Single
Cross Street
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (CASE B) FIELD MEASUREMENTS
Measure and verify the dimensions and slopes:
Landing
Landing
Landing
Landing
Detectable
Detectable
Slope
Cross Slope
Width
Depth
Warning
Warning
(x.x%)
(x.x%)
(inches)
(inches)
Surface Width
Surface Depth
(inches)
(inches)
I1
J1
K1
L1
M1
N1
I2
J2
K2
L2
M2
N2
I3
J3
K3
L3
1.7% or less?
1.7% or less?
59.75" or
49.75" or
Extends full
Minimum 36"?
greater?
greater?
width and less
than 1" gap on
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
either side
Yes
No
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.
CURB RAMP (CASE B) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 4 of 10
CEM-5773B (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Passageway Type
Northwest
Southwest
Single
Cross Street
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (CASE B) FIELD MEASUREMENTS
Measure and verify the dimensions and slopes:
Left
Left
Left
Right
Right
Right
Ramp
Ramp
Ramp
Ramp
Ramp
Ramp
Slope
Cross Slope
Width
Slope
Cross Slope
Width
(x.x%)
(x.x%)
(inches)
(x.x%)
(x.x%)
(inches)
O1
P1
Q1
R1
S1
T1
O2
P2
Q2
R2
S2
T2
O3
P3
Q3
R3
S3
T3
7.7% or less?
1.7% or less?
47.75" or
7.7% or less?
1.7% or less?
47.75" or
greater?
greater?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
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.
CURB RAMP (CASE B) AMERICANS WITH DISABILITIES ACT (ADA)
COMPLIANCE INSPECTION REPORT
Page 5 of 10
CEM-5773B (REV 11/2017)
CONTRACTOR NAME AND ADDRESS
CONTRACT NUMBER/CO/RTE/PM
PROJECT IDENTIFICATION NUMBER
PROJECT INFORMATION/NAME
Location Number
Route Name
Intersection Quadrant
Passageway Type
Northwest
Southwest
Single
Cross Street
Northeast
Southeast
Dual Ramp 1
Mid-Block
Dual Ramp 2
ADA CURB RAMP (CASE B) FIELD MEASUREMENTS
Measure and verify the dimensions and slopes:
Left Side
Left Side
Right Side
Right Side
Conforming Sidewalk
Conforming Sidewalk Cross Slope
Conforming Sidewalk
Conforming Sidewalk Cross Slope
Slope within 4' of top of ramp
within 4' of top of ramp
Slope within 4' of top of ramp
within 4' of top of ramp
(x.x%)
(x.x%)
(x.x%)
(x.x%)
U1
V1
W1
X1
U2
V2
W2
X2
U3
W3
5.2% or less?
Yes
No
1.7% or less?
Yes
No
5.2% or less?
Yes
No
1.7% or less?
Yes
No
If "No," is the sidewalk adjacent to
If "No," is the conforming sidewalk
If "No," is the sidewalk adjacent to
If "No," is the conforming sidewalk
the roadway and the sidewalk grade
a transition to an existing sidewalk?
the roadway and the sidewalk
a transition to an existing sidewalk?
does not exceed the roadway
grade does not exceed the roadway
Yes
No
Yes
No
grade?
Yes
No
N/A
grade?
Yes
No
N/A
If "Yes," the 1.7% or less
If "Yes," the 1.7% or less
requirement does not apply.
requirement does not apply.
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.
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