Reasonable Accommodation Verification Form printable pdf download

Reasonable Accommodation Verification Form

REASONABLE ACCOMMODATION

VERIFICATION FORM

Date: ____________________

Name and Address of Verification Source:

_______________________________________________________________

Head of Household: ______________________________________________

Name of the household member needing accommodation:

_______________________________________________________________

The individual listed above has identified him or herself as having a disability

and has asked for an accommodation from this agency to meet certain needs

dictated by the disability.

The Homeless Service Provider grants reasonable accommodation requests

based in part by verification of need from a qualified professional who has

direct experience with an individual’s disability. Individuals qualified to

complete this form are counselors, social workers, physicians, psychiatrists,

professionals at non-medical service agencies, peer support groups, or a

reliable third party who is in a position to know about the client’s disability.

DC Homeless Service providers are required by law to provide reasonable

accommodations to applicants/residents with disabilities that will provide them

with equal opportunity to use and enjoy our programs, their unit and/or

common areas. Homeless Service programs do not provide accommodations

when the request is a matter of convenience or preference only.

You have been authorized to release information to us regarding the need for

an accommodation/modification.

_______________________ has requested that ________________________

(Client Name)

(Shelter/Housing Program)

in Washington, D.C. provide the following accommodation(s):

_______________________________________________________________

TCP Reasonable Accommodation Verification Form

Reasonable Accommodation Verification Form