HomeMy WebLinkAboutDHR EO 017 County of Hawai'i Request for Modification Form DHR EO 017
CONFIDENTIAL
County of Hawaii
Request for Modification Form
Name: Telephone No.:
Name of Representative (if applicable):
Address or other contact information:
Modification Requested for access to County of Hawaii:
❑ Facility (please name):
❑ Program (please name):
❑ Policy or Procedures:
❑ Other:
What are you requesting? (Please be as specific as possible.)
Is your request time sensitive? [ Yes ❑ No
If yes, please explain fully.
Reason for the Modification Request
What aspect of our facility, program, and/or service are you having difficulty
accessing?
Reasonable Accommodation Request Form CONFIDENTIAL
DHR EO 017
Page 2 of 3
What limitation(s) is/are preventing you from accessing our facility, program,
and/or service?
How will the modification you requested help you?
What will happen if your request is not granted?
I understand that I cannot request an additional modification to this facility,
program, or service for a five-year period unless there is a change in my
limitations or a modification is necessary because of a geographic move.
Signature Date
Reasonable Accommodation Request Form CONFIDENTIAL
DHR EO 017
Page 3 of 3
For County use only:
Received by:
Name Date
ACTIONS TAKEN:
Date Action