HomeMy WebLinkAboutDHR EO 017 Request for Modification Form - Amended 02-07-2020 DHR EO 017
Amended: February 7, 2020
CONFIDENTIAL
County of Hawaii
Request for Modification Form
Name: Telephone No.:
Name of Representative (if applicable):
Address or other contact information:
Do you have a disability as defined under the American's with Disability Act?
❑ Yes
❑ No
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.
Request for Modification Form CONFIDENTIAL
DHR EO 017
Page 2 of 3
Reason for the Modification Request
What aspect of our facility, program, and/or service are you having difficulty
accessing?
How will the modification you requested help you?
Would you like us to consider any other information that is relevant to your
request?
Signature Date
Request for Modification Form CONFIDENTIAL
DHR EO 017
Page 3 of 3
For County use only:
Received by:
Name Date
ACTIONS TAKEN:
Date Action