ADA ACCOMMODATIONS REQUEST FORM-Supreme Court of Louisiana
Information provided in the following form shall be kept as confidential as is possible. However, persons involved in making decisions to provide an accommodation, as well as those processing this request, must necessarily be informed of the type and nature of the request.
|APPLICANT (name): SSN:|
|APPLICANT IS: __ Employee
Job Applicant __Other
Person submitting request (If different from applicant): __________________________________________________________
APPLICANT’S ADDRESS: ____________________________________________________________________________________________________________
Applicant requests accommodation as follows:
1. Proceedings/activities to be covered (e.g.: essential job functions, hearings, meetings, job interviews, visits to court facility, library usage):
2. Date(s) accommodations needed:
3. Impairment necessitating accommodations (specify):
4. Type of accommodations desired (be specific):
5. How will this accommodation assist you in the activity specified in item #1?
6. Special requests or anticipated problems (specify):
I declare under penalty of perjury under the laws of the State of Louisiana that the foregoing is true and correct.
__________________________________________________ _____________________________________ _____________
(TYPE OR PRINT NAME) (SIGNATURE OF APPLICANT) (DATE)
FOR COURT USE ONLY
DATE OF REQUEST:_____________________________
Application reviewed by _________________________________________ ____________________________________
Additional medical information requested __ Yes __ No If yes, copy attached.
Requested accommodation(s) granted and arranged__ Alternative accommodations granted __
Cost of Accommodation $ ____________________________ Applicant notified of decision on (date) ______________________
_________________________________________________ _____________________________ _____________________
(NAME) (TITLE) (DATE)