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DHR EO 017 <br /> CONFIDENTIAL <br /> County of Hawaii <br /> Request for Modification Form <br /> Name: Telephone No.: <br /> Name of Representative (if applicable): <br /> Address or other contact information: <br /> Modification Requested for access to County of Hawaii: <br /> ❑ Facility (please name): <br /> ❑ Program (please name): <br /> ❑ Policy or Procedures: <br /> ❑ Other: <br /> What are you requesting? (Please be as specific as possible.) <br /> Is your request time sensitive? [ Yes ❑ No <br /> If yes, please explain fully. <br /> Reason for the Modification Request <br /> What aspect of our facility, program, and/or service are you having difficulty <br /> accessing? <br />