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