SOP 103.63-att-1: Offender ADA Accommodation Request Form

SOP 103.63
_CONFIDENTIAL_ Attachment 1
4/20/18
Offender ADA Accommodation Request Form

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THIS FORM MUST BE COMPLETED IN INK. YOU MUST INCLUDE SPECIFIC INFORMATION CONCERNING YOUR ALLEDGED ADA CONCERN TO
INCLUDE THE EXACT REASONABLE ACCOMMODATION REQUESTED.

Please describe the alleged denial of services, activities, programs or benefits and your reason(s) for concluding that the conduct
was discriminatory. Please include the name(s) of witnesses, if any, and attach supporting data, if available.

ACCOMMODATION REQUESTED:

Offender Signature Date

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RECEIPT FOR ADA ACCOMMODATION REQUEST AT COUNSELOR'S/FACILITY ADA COORDINATOR LEVEL

OFFENDER'S NAME _______________________________________________________ GDC I.D. #: ______________________________________

I ACKNOWLEDGE RECEIPT OF THE ADA ACCOMMODATION FORM FROM THE ABOVE OFFENDER.

DATE: ______/______/_______ COUNSELOR'S/STAFF MEMBER’S/FACILITY ADA COORDINATOR’S SIGNATURE ______________________________________

Retention Schedule: Upon completion, the original of this attachment shall be placed in the offender’s institutional file and retained according to the official retention
schedule for this file. A copy of this attachment shall be placed in the medical file and mental health file, as necessary, and retained according to the official retention
schedule for that file. A copy of this attachment shall also be maintained in the Facility ADA Coordinator’s and Agency’s ADA Coordinator’s offices for four (4)
years following the final decision of the request.