Shopping Cart
Your Cart is Empty
Quantity:
Subtotal
Taxes
Shipping
Total
There was an error with PayPalClick here to try again
CelebrateThank you for your business!You should be receiving an order confirmation from Paypal shortly.Exit Shopping Cart

Request for Accommodations 

Request for Accommodations

Youth, Staff and Other Stakeholder

1. What type of accommodation are you requesting?

Type of Accommodation Barrier Description Mark “X” is requested

A. Architecture Examples include lack of ADA physical site compliance, lighting, signs in Braille when appropriate

Describe barrier if “X” marked

B. Environment Examples include lack of safety considerations, confidentiality, noise control, appropriate/comfortable furnishings

Describe barrier if “X” marked

C. Attitudes Examples include lack of person-first language, fair treatment, input from persons served utilized, inclusive practices, non-stigmatizing treatment/language

Describe barrier if “X” marked

D. Finances Pay issues, rate of pay

Describe barrier if “X” marked

E. Employment Examples include lack of ADA compliance, DOL compliance

Describe barrier if “X” marked

F. Communication Examples include lack of use of TDD phone services, materials in languages or formats understood by persons served

Describe barrier if “X” marked

G. Technology Examples include lack of training for usage, access to devices when appropriate, access to virtual/telehealth services

Describe barrier if “X” marked

H. Transportation Examples include lack of wheel-chair accessible vehicles, access to public transportation resources

Describe barrier if “X” marked

I. Community Integration Examples include lack of wheel-chair accessible sidewalks in community, adaptive sports programs in community

Describe barrier if “X” marked

J. Other Any other barriers identified by persons served, personnel, or other stakeholders

Describe barrier if “X” marked

2. If you are not sure what accommodation is needed, do you have any suggestions about what options we can explore?

(Circle one) Yes No If yes, please explain.

3. Is your accommodation request time sensitive?

(Circle one) Yes No If yes, please explain.

4. If you are requesting a specific accommodation, how will that accommodation assist you?

5. Please provide any additional information that may be useful in processing your accommodation request.

Requesting Party

Name of Youth, Staff Member or Stakeholder: Date Submitted:

Address: _______ Phone:

Reviewing Party

Reviewer 1: Clinician or Supervisor Level

Date Received: By: Title:

Comments:

Reviewer 2: Supervisor or Director Level

Date Received: By: Title:

Comments:

Reviewer 3: Decision

COO, CEO, General Director or Designated Authority

Date Received: By: Title:

Decision Summary:

Notification of Decision Comments: