ADA Accommodation Request Form

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Person needing accommodation:

Name

Are you:

Other

Street Address

Street Address 2

City

State

Zip

Phone Number

Alternate Phone

Person making request IF different than the person needing accommodation:

Name

Relationship to person needing accommodation:

Street Address

Street Address 2

City

State

Zip

Phone Number

Alternate Phone

Case Information:

County in which case is filed:

Case Number:

Case Type:

Date accommodation is needed:

Time accommodation is needed:

Type of Proceeding:

Hearing Trial Mediation

Accommodation(s) Requested:

Describe the nature of the disability that requires accommodation(s):

Accommodation(s) Requested:

Assistive Listening Device - Increases loudness of sounds, minimizes background noises and overrides poor acoustics. The listened uses a receiver with headphones or similar device. Communication access real-time translation/transcription services - Spoken words are available word for word in a speech to text format on a computer screen to be read. Sign Language Interpreter - (Includes American Sign Language, lip reader, etc.) Assignment to a courtroom that is accessible to a person using a mobility device - (Please specify wheelchair, scooter, walker, etc.) Provisions of court documents in an alternative format - Examples include Braille, large print, or other format for persons who are blind or have low vision.

Other - Please describe:

In some instances, documentation from a qualified health care provider may be required. These requests will be limited to documentation that (a) establishes the existence of a disability, (b) identifies the individual’s functional limitations, and (c) describes how the requested accommodation addresses those limitations. Any cost for obtaining documentation shall be the responsibility of the person requesting the accommodation.

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Third Judicial Circuit Court

ADA Accommodation Request Form

Person needing accommodation:

Person making request IF different than the person needing accommodation:

Case Information:

Accommodation(s) Requested:

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