SOP 103.63-att-3: ADA Accommodation Request Appeal Form

SOP 103.63
Attachment 3

4/20/18
DATE APPEAL RECEIVED FROM OFFENDER_________________________________________

ADA ACCOMMODATION REQUEST APPEAL FORM

______________________ _____________ _________________________________
OFFENDER NAME I.D. NUMBER ADA ACCOMMODATION NUMBER

I reject the Warden’s/Superintendent’s response to my ADA Accommodation Request. The basis for this
appeal is as follows:
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NOTE: The option to appeal a proposed resolution rests with the offender. All ADA request denials indicating a desire for appeal
will be forwarded to the next level. However, to allow a full review of all issues the offender wishes considered, he or she should
state these reasons clearly in the appeal. Statements such as "not satisfied" or "appeal further" will result only in a general review.
This appeal form, along with supporting documents, must be submitted to the Commissioner’s Designee at P.O. Box 1529, Forsyth,
Georgia 31029 within seven (7) days of receipt of the Warden’s/Superintendent’s response.

# OFFENDER’S SIGNATURE: ______________________________________DATE:

(Reproduced locally)
# --------------------------------------------------------------------------------------------------------------

RECEIPT FOR ADA ACCOMMODATION REQUEST APPEAL FORM

AT THE COMMISSIONER’S DESIGNEE LEVEL

OFFENDER’S NAME: I.D.#

I ACKNOWLEDGE RECEIPT OF ADA REQUEST APPEAL NUMBER FROM THE ABOVE
OFFENDER.

DATE: / / COMMISSIONER’S DESIGNEE’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, Agency’s ADA Coordinator’s, and Commissioner’s Designee’s offices for four (4) years following the final decision of the request.