12/31/18 O:\Ra\Request
REQUEST FOR REASONABLE ACCOMMODATION
(Confidential Information. This information will not be disclosed or released, except as permitted by law.)
Name:
Telephone:
Address:
The following member of my household has a disability:_______________________________________
Please provide the following change or changes so that the person listed above may fully access and
utilize the housing programs.
.
Check (
) the kind of change(s) you need
.
A change in the following policy or practice or the way you do things.
Please tell us what you need:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Other: ____________________________________________________________________________
I need this reasonable accommodation because:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
You may verify the need for this request by contacting:
Name:
Address:
I give you permission to contact the above individual for purposes of verifying that a family member or
I need the reasonable accommodation requested.
Applicant/Participant Signature:
Date:
OFFICE USE ONLY (do not write below this line)
Summary of Reasonable Accommodation Approved: Date/Initials:
Notification Details: Date/Initials:
Logged:
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signature
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10/24/17 Verification for RA
VERIFICATION FOR REASONABLE ACCOMMODATION
The following program participant has requested a reasonable accommodation to the Housing Authority’s
rules, policies, procedures or practices (See reverse side of this form.) It is necessary that a qualified
professional complete this form to verify the need for the specific accommodation requested
Disabled family member: _____________________________________________
1. Qualification of person verifying need for reasonable accommodation:
I, ___________________________, am a ____________________________ professional and have the
following certification or qualification: _________________________________________________
2. Nature of contact the professional has had with the person making the request:
I have treated the above client since ___/____/____ for a mental or physical condition. I have evaluated
and/or treated the above client _____ times in the last twelve months.
3. Disability verification. An individual with a disability is any person who has a physical or mental
impairment that substantially limits one or more major life activities, has a record of such impairment or
is regarded as having such an impairment. This may include, but is not limited to, diseases or
conditions such as orthopedic, visual, speech and hearing impairments, cerebral palsy, autism, epilepsy,
muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, HIV, mental retardation,
emotional illness, drug addiction (other than addiction caused by current, illegal use of a controlled
substance) and alcoholism.
Does the above family member meet this definition? Yes No
4. Is the requested accommodation (see question 2 on the reverse side of this form) necessary in order to
afford him/her the opportunity for full use and enjoyment of the program? Yes No
5. IMPORTANT. Describe how the accommodation that the client is requesting is necessary to afford
him/her the opportunity for full use and enjoyment of the program. Please relate the requested
accommodation to the limitation(s) caused by the disabling condition. There must be an identifiable
relationship between the request and the disability unless obvious or otherwise known.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
(WARNING: According to 18 USC Part 1, Chapter 47, Section 1001: It is against the law to knowingly provide false
information or fraudulent statements regarding participants in federally assisted housing programs. Persons providing
such false/fraudulent information or statements are subject to fine, or imprisonment, or both).
Signature of qualified professional: ______________________________________ Date: ______________
Phone number:_______________________________________
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signature
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