The American With Disabilities Act (Ada) Attestation Form printable pdf download

The American with Disabilities Act (ADA) Attestation

Provider Name (print): __________________________________________________________________

Date: ________________

Provider Signature: ____________________________________________________________________

ProviderAddress:_______________________________________________________________________

_____________________________________________________________________________________

Specialty: ____________________________________________________________________________

The Americans with Disabilities Act (ADA) is a federal statute that requires public accommodations to

provide goods and services to people with disabilities on an equal basis as that provided to the general

public. Structural barriers to access should be removed only when the correction is readily achievable,

which is defined by the law as easily accomplished and able to be carried out without much difficulty or

expense. ValueOptions is required to report aggregate statistics by geographic area and specialty on the

percentage of providers that practice in ADA compliant facilities. Toward that end, we request that you

respond to the following questions. Important: A new form needs to be completed and submitted to

ValueOptions each time a practitioner joins a new office or has moved to a new location.

Please enter your overall assessment based on the answers provided in the ADA Checklist. If an ADA

Objective in either the Access to Facility from the Exterior or Access to Interior Spaces sections is

answered NO, then the office is not considered accessible from points of entrance to exam rooms. If an

objective is italicized it should not be considered as part of your summary assessment. If an ADA

Objective in the Access to Public Lavatory section is not italicized and is answered NO, then the public

lavatory is not considered accessible.

Access to Facility from the Exterior

1. Does the office have at least one wheelchair-accessible path from an

entrance to an exam room?

Yes

Examination tables and all equipment are accessible

to people with disabilities.

Yes

If parking is provided, spaces are reserved for people with

disabilities, pedestrian ramps at sidewalks, and drop-offs.

Yes

4. If parking is provided, are there an adequate number of parking spaces provided

(8 feet wide for a car and 5 foot access aisle)?

Yes

Total Spaces

Accessible Spaces

1-25

26-50

51-75

76-100

The American With Disabilities Act (Ada) Attestation Form