Executive Branch Entity Designation of ADA/504 Coordinator
In accordance with Executive Order 526, each Executive Branch Entity shall appoint an ADA/504
Coordinator who shall report directly to the Executive Branch Entity head and work with the
Massachusetts Office on Disability concerning issues involving persons with disabilities, and
where state employee matters are involved with the Office of Diversity and Equal Opportunity.
Notification of such appointment shall be made to the Massachusetts Office on Disability at the
address below.
1. Executive Branch Entity Name
2. ADA/504 Coordinator’s Name
3. E-Mail 4. Phone
5. Address
6. Job Title
7. Date Appointed
_______________
8. Is this appointment?
PERMANENT ACTING
9. Does ADA/504 Coordinator report directly to the appointing authority?
YES NO
FULL TIME?
10a. If part time, what % of an FTE?
11. Direct Supervisor Name Title
Information Or Training Needed for the Coordinator (check all that apply)
a. Employment Rights f. Public Program Access
b. Education Rights g. Privacy Protections
c. Housing Rights h. Other (Please Specify)
d. Open Meetings Laws
e. Physical Barrier Removal
Signatures
Appointing Authority Date
___________
ADA/504 Coordinator Date
___________
ADDRESS QUESTIONS TO:
Moss R. Lynch at Moss.R.Lynch@mass.gov or at 617-979-7319
SUBMIT COMPLETED DESIGNATION TO:
Moss R. Lynch
Massachusetts Office on Disability
One Ashburton Place, #1305 - Boston, MA 02108
