HHSA - Reasonable Accommodation

Nevada County HHSA Reasonable Accommodation Request Form
Title II of the ADA and California Government Code Section 11135 require CWDs to make reasonable modifications (also known as reasonable accommodations) to their policies, practices, and procedures when necessary to provide equal access to people with disabilities. (28 CFR 35.130(b7i In accordance with our statutory responsibilities and management policies, accommodations may be necessary to afford person with disabilities an equal opportunity to access our programs and benefits. You may complete and return this form via mail or to HHSA staff to request accommodation, though this for is not required. You may also request accommodation via, in person or inwriting at any HHSA office.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of Request

MonthDayYear
Date
Please describe the Reasonable Accommodation that you are requesting
Should be Empty: