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Reasonable Accommodation Request Form CONFIDENTIAL <br /> DHR EO 017 <br /> Page 2 of 3 <br /> What limitation(s) is/are preventing you from accessing our facility, program, <br /> and/or service? <br /> How will the modification you requested help you? <br /> What will happen if your request is not granted? <br /> I understand that I cannot request an additional modification to this facility, <br /> program, or service for a five-year period unless there is a change in my <br /> limitations or a modification is necessary because of a geographic move. <br /> Signature Date <br />