Fillable City of Chandler, Arizona chandleraz.gov Disability-Related Request for (City of Chandler)

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City of Chandler, Arizona chandleraz.gov Disability-Related Request for (City of Chandler)

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ADA Modification Request Form Rev. Date: October 28, 2019
CC Reg. No. CA-01 (Att. C-1) - 1 -
City of Chandler, Arizona
chandleraz.gov
_______________________________________________________
Disability-Related Request for Barrier Removal/
Request for Reasonable Modification and/or
Auxiliary Aids and Services
Members of the public who seek a modification to a facility, policy, practice, service, or
program of the City of Chandler or require auxiliary aids or services in order to provide an
equitable opportunity for an individual with a disability to participate may make such a
request directly to the City department responsible for the program, service, or activity
involved or to the City's ADA Coordinator. A request for barrier removal/request
for reasonable modification or auxiliary aids and services may be made by letter, e-mail,
phone call, or by using this form.
Date of Request:
Name of Requesting Party or Authorized Representative:
Street Address:
City, State, Zip code:
Phone: Alternate Phone:
Email:
Program, Facility, or Activity Involved or Location of Barrier:
Reasonable modification(s) and/or auxiliary aid(s) or service(s) requested:
My disability impairs my ability to fully participate in the program/activity in the following
way (check all that apply and/or describe):
Hearing/Communicating
Developmental/Behavioral
Mobility Vision
Other
(Describe):
ADA Modification Request Form Rev. Date: October 28, 2019
CC Reg. No. CA-01 (Att. C-1)
- 2 -
Please provide any details that may be important to reviewing this request:
I understand that my request will be
reviewed and I may be requested to provide
additional information before it is processed. I also understand that the City will make
every effort to act on my request before the start of a program or activity but delays are
possible, particularly when a request is made fewer than two weeks in advance.
Signature:
Date:
Attach additional pages as necessary.
If you need assistance, require an accessible format, or have questions about this form,
please contact ADA Coordinator, Jason Crampton at ada.coordinator@chandleraz.gov
,
480-782-3402 or 711 via AZ Relay Service (AZRS).
INTERNAL USE ONLY - THE FOLLOWING IS TO BE COMPLETED BY CITY STAFF
Department: ___________________ E-mail: _____________________ Phone:
Request for modification/aid/service is: ____ Approved
____ Modified
____ Denied
Name and title of person(s) making decision:
Description of Modification/Aid/Service Provided or Reason for Denial (attach backup or additional
documentation as needed). All denials must be supported by a written rationale and approved
by Department Director, or designee.
Requester Notified: Date: By (name):
Via:
�
Phone
�
Email
�
Letter
�
In Person
Signature:
Date:
Requesters with complaints about the process should see the City of Chandler ADA Grievance Policy
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City of Chandler, Arizona chandleraz.gov Disability-Related Request for (City of Chandler)

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Completed 12 February 2021

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