Reasonable Accommodation Verification Form (Page 2 of 2) in pdf

Reasonable Accommodation Verification Form Page 2

The Americans with Disabilities Act defines a “disability” as a physical

or mental impairment which substantially limits one or more of a

person’s major life activities, a record of having such an impairment,

or being regarded as having such an impairment.

1. Does this individual have a disability, as defined above? Yes ____ No ____

2. If yes, does this individual, because of this disability, need an

accommodation/modification in any rules, policies, practices, or services of

the Homeless Service Provider to have an equal opportunity to use and

enjoy shelter/housing services? Yes _____ No _____

3. If yes, please describe the accommodations/modifications needed:

_______________________________________________________________

The information you provide will be used to determine whether to

grant the accommodation request and may also be used in legal

proceedings.

Name: ________________________ Title: ___________________________

Agency/Institution:_______________________________________________

Address: _______________________________________________________

Fax: _________________________ Phone: ___________________________

Signature: _____________________________ Date: _____________

Reasonable accommodations are time sensitive. Please return this form as

soon as possible to:

[Insert Agency name, Address and fax number]

TCP Reasonable Accommodation Verification Form

Reasonable Accommodation Verification Form Page 2