SubmitcopyofcompletedformtoHumanResources Revised1/3/2013
R
EPORTOF
A
CCOMMODATION
/M
ODIFICATION
Applicant‐Parent/Patron‐School/Department
Requests for accommodations or modifications for Jordan School District sponsored activities or events
madefewerthan72hourspriortotheeventwillbehonoredtothemaximumextentfeasible.
ActionTaken
Datesubmittedtoprincipal/administrator:
Completiondate: Costpaidby:

Requestfulfilled(Pleasespecifyhow):


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Requestnotfulfilled(Pleasestatereason):

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Signature Date
Applicantforemployment Parent/Patron School/Department
 
Individualcompletingform: PhoneNo.:
Person(s)requestingaccommodation:

PhoneNo.ofperson(s)requestingaccommodation:
Ifknown,pleasespecifytheschool/programresponsibleforsponsoring theactivity/event,policy,
communication,orserviceforwhichyouareseekinganaccommodation:
Date(s)/time(s)accommodationneeded:
Limitation(s)necessitatingaccommodation:
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Reasonforrequestingaccommodation
(checkallthatapply):
toparticipateinaprogramoractivityofferedbyJordanSchoolDistrict.Pleasespecifyprogram/activity:
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anexceptiontoarule,policyorprocedure.Pleasespecifytherule,policy,orprocedure:
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
toaccessaDistrictfacility.Pleasespecifyfacility:
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other(pleasespecify):
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Pleasespecif
y
requestedaccommodation(e.g.signlanguageinterpreter,facilitymodification,materials,
procedures,orspecialequipment):