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: 9 Employee 9 Visitor 9 Attorney 9 Job Applicant 9Other (specify)___________________________

Person submitting request (If different from applicant): __________________________________________________________

APPLICANT’S ADDRESS: ____________________________________________________________________________________________________________

TELEPHONE NO: ___________________________________________________________________

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 _________________________________________ ____________________________________

                                  (NAME)                                                                                      (TITLE)

Additional medical information requested Yes 9 No 9 If yes, copy attached.

Requested accommodation(s) granted and arranged 9 Alternative accommodations granted 9

Cost of Accommodation $ ____________________________ Applicant notified of decision on (date) ______________________

_________________________________________________ _____________________________ _____________________

(NAME)                                                                                                        (TITLE)                                                         (DATE)