Office of Planning, Environment, & Realty (HEP)
Planning • Environment • Real Estate
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Identify a place to perform the assessment walk. If you are completing the checklist as a group, try brainstorming collectively to identify important pedestrian routes throughout your community. If you are completing the checklist as an individual, you might want to focus on routes you use regularly, such as from your house to the bus stop. Your walk should be no longer than six blocks.
Complete the contact information and review the checklist questions before you begin your walk. In addition to this form, you may want to bring a notebook, camera and/or sketch pad to record additional information, and a map of the area to mark your route.
Developed by Beneficial Designs
Contact Information
Name: ________________________________________________________________
Address: ______________________________________________________________
City: ________________ State: ________________ Zip: _______________________
Phone: _____________________ Email: ____________________________________
Gender: male/female Age: ________________________________________________
Description of Disability (if any): ___________________________________________
Type of Assistive Technology (if any): _______________________________________
Location of Route: ______________________________________________________
______________________________________________________________________
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If you are not able to answer yes to a question, check as many problems as are applicable. In addition, please note the approximate locations where you encountered each problem.
Other:______________________________________________________
___________________________________________________________
Locations of problems: ________________________________________
___________________________________________________________
Other:______________________________________________________
___________________________________________________________
Locations of problems: ________________________________________
___________________________________________________________
Other:______________________________________________________
___________________________________________________________
Locations of problems: ________________________________________
___________________________________________________________
Other:______________________________________________________
___________________________________________________________
Exact Location of problematic Curb ramps: _______________________
___________________________________________________________
Other:______________________________________________________
___________________________________________________________
Locations of problems: ________________________________________
___________________________________________________________
Other:______________________________________________________
___________________________________________________________
Locations of problems: ________________________________________
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