Request for Accommodations

Youth, Staff and Other Stakeholder________________

1.What type of accommodation are you requesting?________

Type of AccommodationBarrier DescriptionMark “X” is requested

___A.ArchitectureExamples include lack of ADA physical site compliance, lighting, signs in Braille when appropriate

Describe barrier if “X” marked

___B.EnvironmentExamples include lack of safety considerations, confidentiality, noise control, appropriate/comfortable furnishings

Describe barrier if “X” marked

___C.AttitudesExamples 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.FinancesPay issues, rate of pay

Describe barrier if “X” marked

___E.EmploymentExamples include lack of ADA compliance, DOL compliance

Describe barrier if “X” marked

___F.CommunicationExamples include lack of use of TDD phone services, materials in languages or formats understood by persons served

Describe barrier if “X” marked

___G.TechnologyExamples include lack of training for usage, access to devices when appropriate, access to virtual/telehealth services

Describe barrier if “X” marked

___H.TransportationExamples include lack of wheel-chair accessible vehicles, access to public transportation resources

Describe barrier if “X” marked

___I.Community IntegrationExamples include lack of wheel-chair accessible sidewalks in community, adaptive sports programs in community

Describe barrier if “X” marked

___J.OtherAny 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:_____________________________