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Americans With Disabilities Act (ADA) Accommodation Request Form
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This form can be completed on this page and submitted when finished at the end, or the form can be printed, completed, and sent to:
County Administrator's Office, 1100 Simonton Street, Suite 205, Key West, FL 33040, Phone: 305-292-4441, Fax: 305-292-4544
ADA/Human Resources Coordinator Contact:
Alana Thurston, 1100 Simonton Street, Suite 268, Key West, FL 33040, email: firstname.lastname@example.org, Phone: 305-292-4461, Fax: 305-292-4454
Contact the County Administrator's Office by phoning 305-292-4441, between the hours of 8:30 a.m. - 5 p.m., if you are hearing or voice impaired, call "711."
PERSON MAKING THE REQUEST (if other than individual needing the accommodation):
Other contact information:
INFORMATION ON ACCOMMODATION
Date and time accommodation is needed:
Location accommodation is needed:
Duration for which the accommodation is needed:
Nature of disability that necessitates accommodation:
(Attach additional information or documentation if necessary)
Accommodations Requested: please check one of the following six options
Assistive listening device (work by increasing the loudness of sounds, minimizing background noise, reducing the effect of distance, and overriding poor acoustics with headphones.)
Communication access real-time translation/transcription services (CART is a word-for-word speech-to-text interpreting service for people who need communication access.)
Sign language Interpreter (Specify American Sign Language, oral interpreter, signed English, or other type of signing system used by persons with hearing loss.)
Assignment to a meeting room that is accessible to a person using a mobility device (Specify wheelchair, scooter, walker, or other mobility device that is used.)
Provision of County documents in an alternative format (Specify Braille, large print, accessible electronic document, or other accessible format used by persons who are blind or have low vision)
Other accommodation (Specify.)
It is best practice to give consideration to the accommodation sought as required under title II of the ADA; however, alternative methods that achieve effective communication are permissible. The County may comply with the requirements of this section through such means as redesign of equipment, reassignment of services to accessible buildings, assignment of aides to beneficiaries, home visits, delivery of services at alternate accessible sites, alteration of existing facilities and construction of new facilities, use of accessible rolling stock or other conveyances, or any other methods that result in making its services, programs, or activities readily accessible to and usable by individuals with disabilities. The County is not required to make structural changes in existing facilities where other methods are effective in achieving compliance with this section. The County, in making alterations to existing buildings, shall meet the accessibility requirements of Regulation 35.151 in choosing among available methods for meeting the requirements of this section, the County shall give priority to those methods that offer services, programs, and activities to qualified individuals with disabilities in the most integrated setting appropriate. Auxiliary aid requests will be provided at no charge.
Date request was received:
Name and title of County employee responding to this request:
Additional oral or written information requested?
If so, describe information:
Describe the accommodation(s) granted by the County if an alternative means to provide access to program or service is offered:
Indicate the duration the accommodation will be provided:
If request is denied:
If accommodation is denied, indicate the reason(s) for denial. (If the request is denied, granted only in part, or if an alternative accommodation is granted, a written response must be provided to the individual with a disability. Transmittal of a copy of this section of the accommodation request form by email or by U.S. Mail delivery is one means of providing the written response required. If accommodation is denied due to a finding of undue burden or fundamental alteration, that such determination must be made in writing by the County Administrator.)
Written response provided to requester
Copy of denial is attached to this document for the record
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