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: DSA's Frequently Used Forms
Project Application, Inspector Qualification Record, Verified Report, and Others

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 - 1.19 MB) Revised 01/11/12 || DSA-1.INSTR (PDF 331 KB) Revised 04/11/12
• DSA-1.CP: Application Supplement - Collaborative Process (PDF - 148 KB) Issued 07/20/09; 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 - 1.93 MB) Revised 02/07/12 || Instructions (PDF - 270 KB) Revised 02/07/12
• 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: Verified Report (PDF - 186 KB) Revised 08/31/10 || For Contractors and Inspectors
• DSA-6A/E: Verified Report (PDF - 180 KB) Revised 04/11/08 || For Architects and Engineers
• DSA-10: Project Funding Status Inquiry (PDF - 377 KB) Revised 02/10/11

Forms 100–191: DSA's 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 - 149 KB) Revised 03/09/12
• 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; Fillable
• 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-122: SB 1469 Inspector's Report (PDF - 362 KB) Revised 12/04/08; Fillable
• DSA-123: SB 1469 Certification of Compliance (PDF - 230 KB) Revised 12/04/08; Fillable
• 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-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 - 148 KB) Revised 05/09/12 ||  Instructions (PDF - 151 KB)
• DSA-190: Certification of Excess Flow Automatic Gas Shutoff Valve (PDF - 84 KB) Revised 05/22/09; Fillable
• DSA-191: Certification of Seismic Automatic Gas Shutoff Valve (PDF - 67 KB) Revised 05/22/09; Fillable

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

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

• 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 - 132 KB) Revised 02/16/11
• 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 - 60 KB) Revised 09/22/11  | Non-fillable Version (PDF - 217 KB)
• DSA 220: LEA Program On-site Lab Assessment Report (PDF - 190 KB) Revised 4/19/12
• DSA 250: Special Inspection (PDF - 152 KB) Revised 02/16/11  | Non-fillable Version (PDF - 59 KB)
• DSA-291: Laboratory Verified Report (PDF - 53 KB) Revised 01/16/09 || Instructions (PDF - 44 KB)
• DSA-292: Special Inspection Verified Report (PDF - 99 KB) Revised 09/22/11 || Instructions (PDF - 44 KB)
• DSA-293: Geotechnical Verified Report (PDF - 182 KB) Revised 01/24/12 || Instructions (PDF - 133 KB) Revised 01/24/12
• DSA 300: AB 300 Seismic Safety Inventory Update (PDF - 42 KB) Issued 09/15/08

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 - 442 KB) Revised 02/07/10
• DSA-600: Candidate Eligibility and Certification Renewal Application (PDF - 198 KB) Revised 08/18/11 | Instructions (PDF - 84 KB)
• DSA-601: Voluntary CASp Examination Registration (PDF - 122 KB) Revised 01/25/11
• 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 08/24/11 | Instructions (PDF - 80 KB)
• DSA-605: Continuing Education Equivalency Petition (PDF - 183 KB) Revised 08/24/11 | Instructions (PDF - 80 KB)
• DSA-606: Continuing Education Extension Request (PDF - 141 KB) Revised 08/18/11 | Instructions (PDF - 80 KB)
• DSA-810: Local Fire Authority Review Template (PDF - 145 KB) Revised 04/29/12; Fillable | Instructions (PDF - 212 KB)
• DSA-999: Inspection Verified Report for Projects Exempt from DSA Approval (PDF - 121 KB) Revised 01/06/09