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Local Assistance Procedures Manual EXHIBIT 9-C
Local Agency ADA Annual Certification Form
Exhibit 9-C: Local Agency Americans with Disabilities Act (ADA)
Annual Certification Form
Local Agency ADA Annual Certification Form
49 CFR 27: Nondiscrimination on the Basis of Disability in
Programs or Activities
Receiving Federal Financial Assistance
Local Agency: __________________________________
State Fiscal Year (July 1-June 30): __________________
I.Name of ADA / 504 Liaison Officer: ____________________________________________
Telephone Number:
E-mail Address: ____________________________________________________________
NOTE: Section 504 applies to federally funded programs and ADA applies to state and local government funded
programs (Title II). An ADA Officer is only required if the agency has 50 or more employees.*
II.ADA Grievance / Complaint Procedure Adopted?
Yes: No: ______
If yes, date of completion/last updated:
If no, planned date of adoption:
NOTE: An ADA Officer is only required if the agency has 50 or more employees.*
III.Self-evaluation completed?
Yes: No: ______
If yes, date of completion/last updated:
If no, planned date of completion:
NOTE: All public entities receiving federal funds are required to complete a self-evaluation. Agencies are required to
review and make modifications as needed to the self-evaluation to ensure there is non-discrimination on the basis of
disability. Local agencies shall implement a system for periodically reviewing and updating self-evaluations and, if
applicable, transition plans. As a best practice, it is recommended to review the self-evaluation every three years prior
to submitting or adopting the four-year Transportation Improvement Program.
*The Section 8.1000 in Title II, Technical Assistance Manual states, “How does a public entity determine whether it has
50 or more employees? Determining the number of employees will be based on a governmentwide total of
employees, rather than by counting the number of employees of a subunit, department, or division of the local
government. Part-time employees are included in the determination.”
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Local Assistance Procedures Manual EXHIBIT 9-C
Local Agency ADA Annual Certification Form
IV. Transition Plan completed?
Yes: No: _______
If yes, date of completion/last updated:
If no, planned date of completion:
NOTE: In the event that structural changes to facilities will be undertaken to achieve program accessibility, a public
entity with 50 or more employees are required to develop a transition plan.*
The transition plan is the action plan developed from the results of the self-evaluation. As a best practice, it is
recommended to update the transition plan every three to five years after completion of the recommended self-
evaluation and to update the schedule of ADA compliant changes that will be accomplished.
V. Have your agency’s policies, procedures, and criteria for implementing ADA compliance improvements in
maintenance and capital improvement programs been reviewed?
Yes: No:
Were deficiencies found?
Yes: No:
If deficiencies were found, have the agency’s ADA plans been revised to correct those deficiencies?
Yes: No:
VI. Does the agency have procedures to obtain approval from the Division of State Architect (DSA) for design
packages consistent with State law?
Yes: No:
DSA website: https://www.dgs.ca.gov/DSA/Resources/Page-Content/Resources-List-Folder/Accessibility-
Plan-Review
Reminder: State of California Government Code Sections 4450 -4454 requires DSA to review and
approve the plans and specifications to all buildings, structures, sidewalks, curbs and related facilities
constructed in the state, using state, county or municipal funds, or the funds of any political subdivision of
the state. These facilities shall be accessible to and usable by persons with disabilities. Please reference
Section 9.3 of the Local Assistance Procedures Manual for submittal of design packages to DSA.
The DSA has limited their review to “Safe Routes to School” projects. For ATP Projects, the California
Transportation Commission considers Safe Routes to School projects as those “that directly increase
safety and convenience for public school students to walk and/or bike to school. Safe Routes to Schools
infrastructure projects must be located within two miles of a public school or within the vicinity of a public-
school bus stop and the students must be the intended beneficiaries of the project.”
VII. Are agency’s Standard Plans reviewed and updated on an ongoing basis for full ADA and California
Accessibility compliance?
Yes: No:
Date:
Signature
(ADA Liaison Officer)
Distribution: (1) Original - DLAE
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