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:_____________________________