Transcription of REQUEST FOR REASONABLE ACCOMMODATIONS North …
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REQUEST FOR REASONABLE ACCOMMODATIONS North …
REQUEST FOR REASONABLE ACCOMMODATIONS North Dakota Department of Transportation, Civil Rights SFN 60135 (2-2016)DatePART INameTelephone NumberStreet/Mailing AddressCityStateZIP CodePreferred Method of ContactDay PhoneEmailUSPSE mail AddressType of Event:Public Meeting/Public HearingTrainingOther (specify) _____Date of Eventand/orDate NeededLocation of EventPART II: LIMITED ENGLISH PROFICIENCY (LEP)YesNoDo you need language assistance for LEP?Language AssistanceOral Interpretation (specify language) _____Written Translation (specify language) _____Name of DocumentsPART III: AMERICANS WITH DISABILITIES ACT (ADA)Do you need an accommodation for a disability?YesNoTypes of AccommodationInterpreter for deaf (specify ASL, tactile, etc.) _____Assistive Listening device (specify) _____Physical location accessible for persons with a physical mobility (specify) _____Nature of Disability (Medical documentation may be requested)Physical Mobility Impairment (specify) _____Speech Impairment (specify) _____Visual impairment (specify) _____Hearing Impairment (specify) _____Other (specify) _____For Office Use OnlyThe accommodation REQUEST is:Granted as req
Requests for Reasonable Accommodations can be made by completing this form. If you prefer to complete this form ... If you need assistance to complete the Request for Reasonable Accommodations form, please contact Paula Messmer, Civil …
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