DSA Forms

Many DSA forms are in Adobe Portable Document Format (PDF). To download and print a PDF file, you will need to have the Adobe Reader software installed (Get Adobe Reader).

Forms 1-10: Frequently Used Forms
Project Application, Inspector Qualification Record, Verified Report, and Other Forms

DSA's most frequently used forms include the Application for Approval of Plans and Specifications (Form DSA-1), the Project Submittal Checklist (Form DSA-3), and the Verified Report (Form DSA-6), among others.

• DSA-1: Application for Approval of Plans and Specifications (PDF - 1.20 MB) Revised 08/01/12 || Instructions (PDF 166 KB) Revised 05/15/13
• DSA-1.CP: Application Supplement - Collaborative Process (PDF - 148 KB) Revised 11/16/10
• DSA-1.DEL: Delegation of Responsibility (PDF - 355 KB) Revised 07/15/09
• DSA-1.INC: Definition of Scope of Increments (PDF - 37 KB) Revised 03/10/11; Not Fillable
• DSA-1.REH: Pre-Application for Approval of Evaluation and Design Criteria Report for Rehabilitation of Existing Non-Conforming Buildings for Use as a Public School (PDF - 89 KB) Revised 10/11/11; Not Fillable
• DSA-2: Application for Evaluation of Existing School Building (PDF - 312 KB) Revised 08/31/10
• DSA-3: Project Submittal Checklist (PDF - 2.26 MB) Revised 08/01/12 || Instructions (PDF - 226 KB) Revised 08/01/12
• DSA-4: Application for Review of Eligibility Evaluation Report for the Seismic Mitigation Program (PDF - 117 KB) Revised 09/15/11 || Instructions (PDF - 55 KB)
• DSA-5: Project/Special Inspector Qualification Record (PDF - 396 KB) Revised 11/16/10
• DSA-5A: Assistant Inspector Qualification Record (PDF - 211 KB) Revised 09/17/08
• DSA 6-AE: Verified Report for Architects and Engineers (PDF - 187 KB) Revised 03/22/13
• DSA 6-C: Verified Report for Contractors (PDF - 99 KB) Revised 03/22/13
• DSA 6-PI: Verified Report for Project Inspectors (PDF - 189 KB) Revised 03/22/13
• DSA-10: Project Funding Status Inquiry (PDF - 377 KB) Revised 02/10/11

Forms 100–191: Project-related Forms
LEA, Gas Shutoff Valve and Inspector Program Forms

Forms 100-191 include DSA's forms for the Laboratory Evaluation Acceptance (LEA), Gas Shut-off Valve, and Inspector programs, among others.

• DSA-100: Application for Laboratory Evaluation Acceptance (LEA) Program (PDF - 812 KB) Revised 05/19/11; Fillable || Instructions (PDF - 98 KB) Revised 02/12/13
• DSA-102: Contract Information (PDF - 98 KB) Revised 08/31/10
• DSA-103: Statement of Structural Tests and Special Inspections: 2010 CBC (Excel - 362 KB) Revised 03/19/12 || Instructions (PDF - 64 KB) Revised 04/27/11
  • Opening DSA-103 in Excel 2003 (PDF - 285 KB) Issued 10/15/08
  • Opening DSA-103 in Excel 2007 (PDF - 281 KB) Issued 08/05/10
  • 2007 CBC Version of form DSA-103 (Excel - 385 KB)
• DSA-104: Report Verifying Actual Project Costs - ACS Only Projects (PDF - 84 KB) Issued 7-27-11
• DSA-108: Change in Delegation of Responsibility (PDF - 88 KB) Revised 07/15/09 || Instructions (PDF - 40 KB) Issued 07/15/09
• DSA-109: Transfer of Responsibility: Geotechnical Engineer (PDF - 145 KB) Issued 04/11/12
• DSA-121: Checklist for Site Inspection of Relocatable Buildings (PDF - 350 KB) Revised 09/10/02
• DSA-130: Certificate of Compliance - Approved Bleacher/Grandstand Fabricator (PDF - 112 KB) Revised 01/11/12
• DSA-131: Bleacher/Grandstand Material Certification - Unapproved Fabricator (PDF - 95 KB) Revised 01/11/12
• DSA-140: Application for Approval of Construction Change Document - CCD Category A (PDF - 209 KB) Revised 11/21/12
• DSA-141: Application for Concurrence of Construction Change Document - CCD Category B (PDF - 210 KB) Revised 11/21/12
• DSA-145: Record Set Handling Instructions (PDF - 932 KB) Revised 05/01/07 || Instructions
• DSA-160: Code Appeal Process (CAP) Router (PDF - 92 KB) Revised 12/08/09 || Instructions (PDF - 47 KB)
• DSA 168: Statement of Final Actual Project Cost (PDF - 113 KB) Revised 03/15/13 || Instructions (PDF - 116 KB)
• DSA-190: Certification of Excess Flow Automatic Gas Shutoff Valve (PDF - 134 KB) Revised 08/20/12 || Instructions (PDF - 74 KB)
• DSA-191: Certification of Seismic Automatic Gas Shutoff Valve (PDF - 134 KB) Revised 08/20/12 || Instructions (PDF - 74 KB)

Forms 201–300: Testing Laboratories, Special Inspection & Report Templates Forms

Forms 201-300 include Testing Laboratories, Special Inspector and Report Templates Forms.

• DSA 201: Soil Compaction (PDF - 163 KB) Revised 02/16/11
• DSA 202: Sieve Analysis (PDF - 163 KB) Revised 02/16/11
• DSA 203: Tension/Bend (PDF - 172 KB) Revised 11/13/12
• DSA 204: Compression (PDF - 202 KB) Revised 05/17/11
• DSA 205: Concrete Masonry Unit (PDF - 175 KB) Revised 06/28/11
• DSA 206: Anchor Load (PDF - 152 KB) Revised 02/16/11
• DSA 207: Masonry Core Shear/Compression (PDF - 128 KB) Revised 02/16/11
• DSA 208: High Strength Bolt (PDF - 122 KB) Revised 02/16/11
• DSA 209: Fireproofing Density (PDF - 127 KB) Revised 02/16/11
• DSA 210: Ultrasonic (NDT) (PDF - 140 KB) Revised 02/16/11
• DSA 211: Additional Comments (PDF - 73 KB) Revised 05/17/13 || Non-fillable Version (PDF - 50 KB)
• DSA 220: LEA Program On-site Lab Assessment Report (PDF - 190 KB) Revised 4/19/12
• DSA 250: Special Inspection Report (PDF - 152 KB) Revised 02/16/11 || Non-fillable Version (PDF - 59 KB)
• DSA-291: Laboratory of Record Verified Report (PDF - 201 KB) Revised 05/01/13; Not Fillable
• DSA-292: Special Inspection Verified Report (PDF - 355 KB) Revised 05/01/13; Not Fillable
• DSA-293: Geotechnical Verified Report (PDF - 430 KB) Revised 05/01/13; Not Fillable
  • For important changes to the Verified Report process for LEA Laboratories and Special Inspectors, refer to Guidelines to 2013 Verified Report Changes (PDF - 111 KB).
• DSA 300: AB 300 Seismic Safety Inventory Update (PDF - 42 KB) Revised 01/01/11

Forms 301–320: Closeout & Certification Forms

Forms 301-320 include forms that support the DSA Closeout & Certification program in assisting school districts with closeout and certification of Legacy Projects.

• DSA-310: Alternate Certification Statement of Content for Change Orders, Addenda and Revisions (PDF - 121 KB) Revised 01/08/13
• DSA-311: Request for Examination for Certification Using Education Code 17315(b)/81147(b) (PDF - 152 KB) Revised 01/08/13
• DSA-320: Alternate Certification Process Justification (PDF - 136 KB) Revised 01/08/13

Forms 400–999: Other DSA Forms

Forms 400-999 include the 2008 Energy Code Compliance Checklist (DSA-403) and DSA forms for the Voluntary Certified Access Specialist (CASp) program, among other miscellaneous forms.

• DSA-403: 2008 Energy Code Compliance Checklist (PDF - 147 KB) Revised 02/25/13
• DSA-600: Candidate Eligibility and Certification Renewal Application (PDF - 230 KB) Revised 03/21/13 | Instructions (PDF - 52 KB) Revised 02/07/13
• DSA-601: Voluntary CASp Examination Registration (PDF - 213 KB) Revised 11/16/12
• DSA-602: Requesting Special Accommodation(s) (PDF - 75 KB) Revised 03/24/10
• DSA-603: Questionnaire for Test Accommodations (PDF - 188 KB) Revised 03/24/10
• DSA-604: Continuing Education Course Verification (PDF - 179 KB) Revised 07/25/12 || Instructions (PDF - 80 KB)
• DSA-605: Continuing Education Equivalency Petition (PDF - 183 KB) Revised 07/25/12 || Instructions (PDF - 80 KB)
• DSA-606: Continuing Education Extension Request (PDF - 141 KB) Revised 08/18/11 | Instructions (PDF - 80 KB)
• DSA-650: AB1424 Supplement for Individuals (PDF - 148 KB) Issued 05/29/12
• DSA-650B: AB1424 Supplement for Businesses(PDF - 150 KB) Issued 05/29/12
• DSA-786: Disability Access and Education Fee Report (PDF - 118 KB) Issued 11/28/12
• DSA-810: Local Fire Authority Review (PDF - 145 KB) Revised 04/29/12 || Instructions (PDF - 248 KB) Revised 08/01/12
• DSA-999: Inspection Verified Report for Projects Exempt from DSA Approval (PDF - 121 KB) Revised 01/06/09