MC 70a (10/15) REVIEW OF REQUEST FOR REASONABLE ACCOMMODATIONS AND RESPONSE
Approved, SCAO
REVIEW OF REQUEST FOR
REASONABLE ACCOMMODATIONS AND RESPONSE
MCL 393.501 et seq., 42 USC 12111 et seq.
If your request for accommodations was denied, you can ask for a review of your request. Complete the Applicant section below.
Enter the date and sign your name. Mail or give your completed request to the ADA Coordinator. If you need help completing this
form, contact the ADA coordinator at the above telephone number.
APPLICANT INFORMATION (to be kept confidential)
Witness Juror Attorney Party Other (specify)
1. What type of proceeding or court service, activity, or program are you attending (i.e., hearing, jury duty, mediation meeting, trial)?
2. On what dates do you need accommodations?
3. For what impairment do you need accommodations (for a sign language interpreter, specify ASL, CDI, or CART)?
4. What type of accommodations do you need?
The request is GRANTED
for the above matter or appearance, from to , for an indefinite period,
in whole as follows: (specify the accommodations)
in part. As consented to by the applicant, alternative accommodations are as follows: (specify the accommodations)
The request is DENIED because
the applicant is not a qualified individual with a disability under the ADA.
the request creates an undue financial or administrative burden on the court (as defined by the ADA).
the request fundamentally alters the nature of the service, program, or activity (as defined by the ADA).
The basis for this denial is: (Specify on separate sheet if needed. Include alternative accommodations offered but rejected by the applicant.)
NOTE: If your request is denied, you may submit a written request for review by the State Court Administrator. Send your request
to the State Court Administrative Office, State Court Administrator, Michigan Hall of Justice, PO Box 30048, Lansing, MI 48909.
Court Use Note: This completed and signed Review of Request for Reasonable Accommodations and Response must be maintained with the original Request
in a confidential administrative file.
Date Applicant signature
Date Judge Bar no.
Applicant is
Case name and number (if applicable)
Name E-mail address
Address
City State Zip Telephone no.
Original - Administrative court file
Copy - Applicant
Court name and address
Telephone number of ADA coordinator:
RESPONSE TO REQUEST
