Fillable Form 5: Fifteenth Judicial Circuit ADA Title II (The 15th Judicial Circuit of Florida)

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Form 5: Fifteenth Judicial Circuit ADA Title II (The 15th Judicial Circuit of Florida)

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ADA – Request for Accommodations 5-2018
Fifteenth Judicial Circuit
ADA Title II Accommodation Request Form
Right to an Accommodation
If you are an individual with a disability who needs a reasonable accommodation in order to
participate in a court proceeding or other court service, program, or activity, you are entitled, at
no cost to you, to the provision of certain assistance. Request for accommodations may be
presented on this form, in another written format, or verbally. Please complete the attached form
and return it the Fifteenth Judicial Circuit Court’s ADA Coordinator, 205 North Dixie Highway,
5
th
Floor, West Palm Beach, Florida 33401, Phone Number: 561-355-4380; if you are hearing
or voice impaired, call 1-800-955-8771; Fax number is 561-656-7662; or E-mail at
ADA@pbcgov.org as far in advance as possible, but preferably at least seven (7) days before
your scheduled court appearance or other court activity.
Upon request by a qualified individual with a disability, this document will be made available in
an alternate format. If you need assistance in completing this form due to your disability, or to
request this document in an alternate format, please contact the Fifteenth Judicial Circuit Court’s
ADA Coordinator, 205 North Dixie Highway, 5
th
Floor, West Palm Beach, Florida 33401, Phone
Number: 561-355-4380; if you are hearing or voice impaired, call 1-800-955-8771; Fax
Number is 561-656-7662; or E-mail at ADA@pbcgov.org
ADA Accommodations Provided by Florida Courts
Pursuant to Title II of the Americans with Disabilities Act the Circuit will make reasonable
modifications in policies, practices and procedures; furnish auxiliary aids and services; and
afford program accessibility through the provisions of accessible facilities, the relation of
services or programs or the provision of services at alternative sites, as appropriate and
necessary.
Examples of auxiliary aids or services that the State Court System may provide for qualified
individuals with disabilities include:
Assisted Listening Devices
Sign Language Interpreters
Oral Interpreters
Real-Time Transcription Services
Providing Materials in Large Print, Braille, Diskette, or Audio Tapes
Reader Services
Sound Amplifying Headsets
Accommodations that are granted by the State Courts are made at no cost to qualified individuals
with disabilities.
ADA – Request for Accommodations 5-2018
Aids/Services Courts cannot Administratively Grant as ADA Accommodation
Example of aids or services the Florida State Court System cannot provide as an accommodation
under Title II of the Americans with Disabilities Act include:
Transportation to the Courthouse
Legal Counsel or Advice
Personal Devices such as a Wheelchair or Hearing Aid
Personal Services such as Medical or Attendant Care
A Modification of a Policy or an auxiliary Aid or Service that would result in a
fundamental alteration in the nature of the Program or Service, or would result in an
undue burden
Document filing
Additionally, the courts cannot administratively grant, as an ADA accommodation, requests that
impact court procedures within a specific case. Request for an extension of time, a change of
venue, or participation in court proceedings by telephone or videoconferencing must be
submitted by written motion to the presiding judge as part of the case. The judge may consider
an individual’s disability, along with other relevant factors, ingraining or denying the motion.
Furthermore, the court cannot exceed the law in granting a request for an accommodation. For
example, the court cannot extend the statute of limitations for filing an action because someone
claims that he or she could not make it to court on time due to a disability, nor can the court
modify the terms of agreements among parties as an ADA accommodation.
Finally, the ADA does not require the court system to take any action that would fundamentally
alter the nature of court programs, services, or activities, or that would impose an undue financial
or administrative burden on the courts.
Documentation of the Need for Auxiliary Aids and Services
If an individual has a disability that is not obvious, or when it is not readily apparent how a
requested accommodation relates to an individual’s impairment, it may be necessary for the court
to require the individual to provide documentation form a qualified health care provider in order
for the court to fully and fairly evaluate the accommodation request. These information requests
will be limited to documentation that (1) establishes the existence of a disability; (2) identifies
the individual’s functional limitations; and (3) describes how the requested accommodation
addresses those limitations. Any cost to obtain such documentation is the obligation of the
person requesting the accommodation.
Florida State Courts System Page 4 ADA Accommodation Request Form
FLORIDA STATE COURTS SYSTEM TITLE II ADA ACCOMMODATION REQUEST FORM
Please return this completed form to the Fifteenth Judicial Circuit Court’s ADA
Coordinator, Palm Beach County Courthouse 205 North Dixie Highway, 5th Floor,
West Palm Beach, Fl, 33401, Phone: 561-355-4380, Fax: 561-656-7662; TDD,
1-800-955-8771, Fax, E-mail: ADA@pbcgov.org as far in advance as possible,
but preferably at least seven (7) days before your scheduled court appearance or
other court activity.
1. Date request submitted: ______/______/______
2. Person needing ac
commodati
on
Name: _________________________________________________________________
Are you (please check one of the following seven options):
[ ] Defendant [ ] Litigant/Party [ ] Witness [ ] Juror [ ] Victim [ ] Attorney
[ ] Other (please specify): __________________________________________________
3. Contact information for person needing accommodation
Street or P.O. Box: ________________________________________________________
City: ___________________________________________________________________
State: ___________________________________ Zip Code: _____________________
Telephone Number (include area code): ______________________________________
Email Address: ___________________________________________________________
4. Person making request (if other than the person needing the accommodation)
Name: _________________________________________________________________
Telephone Number (include area code): ______________________________________
Email Address: __________________________________________________________
Relationship to person needing an accommodation: ____________________________
5. Case information (if applicable)
Style of case (case title), if known: __________________________________________
Case number, if known: __________________________________________________
Judge, if known: ________________________________________________________
Date accommodation needed: ______________________________________________
Time accommodation needed: ______________________________________________
Location (courthouse/courtroom) accommodation needed: _______________________
Duration for which the accommodation is requested: ____________________________
Type of case, if known (please check one of the following ten options):
Florida State Courts System Page 5 ADA Accommodation Request Form
[ ] appeal [ ] circuit criminal [ ] circuit civil [ ] family court
[ ] probate, guardianship, or mental health [ ] county criminal [ ] county civil
[ ] traffic court [ ] small claim [ ] other (please specify) ____________________
Type of proceeding, if known (please check one of the following six options):
[ ] arraignment [ ] bond hearing [ ] hearing [ ] trial [ ] appellate oral argument
[ ] other (please specify) __________________________________________________
6. Accommodations requested
Nature of disability that necessitates accommodation: ___________________________
________________________________________________________________________
Accommodation requested (please check one of the following six options):
[ ] Assistive listening device (Assistive listening systems work by increasing the
loudness of sounds, minimizing background noise, reducing the effect of distance,
and overriding poor acoustics. The listener uses a receiver with headphones or a
neckloop to hear the speaker.)
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ZRUGVSHHFKWRWH[WLQWHUSUHWLQJVHUYLFH(YHU\WKLQJVDLGLQWKHFRXUWURRPLQFOXGLQJ
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EHWZHHQWKH&$57SURYLGHUDQGWKHKHDULQJFKDOOHQJHGSHUVRQDQGDWWRUQH\LI
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[ ] Sign Language Interpreter (Please specify American Sign Language, oral
interpreter, signed English, or other type of signing system used by persons with
hearing loss.):
___________________________________________________________________
[ ] Assignment to a courtroom that is accessible to a person using a mobility device
(Please specify wheelchair, scooter, walker, or other mobility device that is used.):_
[ ] Provision of court documents in an alternative format (Please specify Braille,
large print, accessible electronic document, or other accessible format used by
persons who are blind or have low vision.): _________________________________
[ ] Other accommodation (please specify): ____________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
___________________________________________________________________
Florida State Courts System Page 6 ADA Accommodation Request Form
THE FOLLOWING SECTION IS TO BE COMPLETED BY COURT PERSONNEL ONLY
8. Date request was received: ______/______/______
9. Additional oral or written information requested? [ ] Yes [ ] No
If so, describe information: ____________________________________________________
___________________________________________________________________________
10. Describe the accommodation(s) granted by the court: ______________________________
__________________________________________________________________________
11. Indicate the duration the accommodation will be provided: __________________________
___________________________________________________________________________
12. If an accommodation is denied, indicate reason(s) for denial:
3
[ ] Based on the information provided, it appears the person does not have a disability as
defined by the ADA
[ ] Requested accommodation does not directly correlate to functional limitations
[ ] Request relates to a service, program, or activity outside the court system
(transportation, legal representation, mental health counseling, parenting course, etc.)
[ ] Request is for an aid/service the courts cannot administratively grant as an
accommodation pursuant to Title II of the ADA (official transcript, extension of time, etc.)
[ ] Requested accommodation would result in an undue burden
[ ] Requested accommodation would result in a fundamental alteration
[ ] Other (please specify): _____________________________________________________
13. Remarks: __________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
14. Court staff responding to request: ______________________________________________
15. Date person notified of determination: ______/______/______
3
If the request is denied, granted only in part, or if an alternative accommodation is granted,
Rule of Judicial Administration 2.540 requires the court to respond in writing to the individual
with a disability. Transmittal of a copy of this section of the accommodation request form by
email or by U.S. Mail delivery is one means of providing the written response required by rule
2.540. If an accommodation is denied due to a finding of undue burden or fundamental
alteration, the Americans with Disabilities Act requires that such determination be made in
writing by the chief judge or chief judge’s designee.
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Form 5: Fifteenth Judicial Circuit ADA Title II (The 15th Judicial Circuit of Florida)

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Completed 13 June 2021

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