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Americans with Disabilities Act (ADA) Survey

The purpose of this accessibility survey is to determine whether or not a Provider Office has barriers to access by people with a variety of disabilities. Reviewing Offices for accessibility is one of the most effective ways LIBERTY Dental Plan can ensure that Providers are complying with the Americans with Disabilities Act (ADA).

Please understand that our assessment of your ADA compliance is required by The Centers for Medicare and Medicaid Services (CMS).

There are no wrong answers in any parts of the survey. Please choose the answer which best describes your office environment.

Your completed survey will help us to better serve our members. Thank you.

First Name
Last Name
Professional Title
Office Name
Facility ID
Office Address
Office City
Office State
Office Zip Code
Office Phone
---PARKING---
1. Are the correct numbers of accessible parking spaces provided? (1-25 total spaces=1 required;26-50=2 required; 51-75=3 required; 76-100=4 required; 101-150=5 required; 151-200=6 required; 201-300=7 required; 301-400=8 required)
2. Do curbs on the route from off-street public parking have curb ramps at the parking locations?
3. Do curbs on the route from off-street public parking have curb ramps at the drop off locations?
4. Is VAN accessible parking provided?
---EXTERIOR ROUTE --- (from accessible parking, public transportation, and public sidewalk to the entrance)
5a. For exterior routes, if the accessible route crosses a curb, is a curb ramp provided to the building entrance from the parking?
5b. For exterior routes, if the accessible route crosses a curb, is a curb ramp provided to the building entrance from public transportation?
5c. For exterior routes, if the accessible route crosses a curb, is a curb ramp provided to the building entrance from the public sidewalk?
---RAMPS---
6. Is each run (leg) of the ramp no longer than 30 feet between landings?
7. Are handrails provided on both sides of the ramp that are mounted between 34 and 38 inches above the ramp surface, if it is longer than 6 feet?
8. Are all ramps at least 36 inches wide?
---BUILDING ENTRANCE---
9. If a main entrance is not accessible, is there another accessible entrance?
10. Do doors have an opening at least 32 inches wide (at the narrowest point below the opening hardware) when opened to 90°?
11. Is space available for a wheelchair user to approach, maneuver, and open the door?
12. Do entrance doors have handles that can be opened without grasping, pinching, or twisting of the wrist?
---INTERIOR ROUTE--- (from the building entrance to the clinic/office entrance, to the registration counter/window, and through the clinic/office to areas that patients could go)
13. Do entrance doors have handles that can be opened without grasping, pinching, or twisting of the wrist?
14. Are ALL interior paths of travel at least 36 inches wide?
15. If there are stairs on the accessible route, are there handrails on each side?
16. If a platform lift is used, can it be used without assistance?
---ELEVATORS--- (If not applicable, skip to the Restroom section)
17. If needed, is the elevator available for public/patient use during business hours?
18. Is the elevator equipped with both visible and audible door opening/closing and floor indicators?
19. Is there a raised letter and Braille sign on each side of each elevator jamb?
20. Are the hall call buttons for the elevator no higher than 48 inches from the floor?
21. Is the elevator car large enough for a wheelchair or scooter user to enter, turn to reach the controls, and exit?
22. Do the buttons on the control panel inside the elevator have Braille and raised characters/symbols near the buttons?
---RESTROOM---
23. For all toilet rooms with and without stalls: Are grab bars provided, one on the wall behind the toilet and one on the wall next to the toilet?
24. Is the toilet paper dispenser mounted below the side grab bar with the centerline of the toilet paper dispenser between 7 inches and 9 inches in front of the toilet, and at least 15 inches high?
25. Is there a space that is at least 30 inches wide and 48 inches deep to allow wheelchair users to park in front of the sink?
26. Are faucet handles operable with one hand and without grasping, pinching, or twisting? (Check Yes if faucets are automatic.)
27. Toilet room without stalls: Do toilet room doorways have a minimum clear opening of 32 inches with the door open at 90 degrees, measured between the face of the door and the opposite stop?
28. Toilet Room with stalls: Is there a 60-inch diameter turning circle or a 60 inch x 60 inch "T"-shaped space inside the toilet room with stalls to allow a turnaround for wheelchair and scooter users?
---EXAM ROOM---
29. Do exam room doorways have a minimum clear opening of 32 inches with the door open at 90 degrees, measured between the face of the door and the opposite stop?
30. Is there a 60 inch diameter turning circle or a 60 inch x 60 inch "T"-shaped space so that a wheelchair or scooter user can make a 180° turn?
---OTHER---
31. Is there Public Transportation available within ½ mile of office location?
32. Special experience, skill, expertise, or training in treating persons with (please check all that apply):







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