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DHR EO 017 <br /> Amended: February 7, 2020 <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 /> Do you have a disability as defined under the American's with Disability Act? <br /> ❑ Yes <br /> ❑ No <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 />