HomeMy WebLinkAboutDHR EO 017 Request for Modification Form (Fillable) - Amended 02-07-2020.pdfDHR EO 017 Amended: February 7, 2020
CONFIDENTIAL
County of Hawai‘i 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 Hawai‘i:
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
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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
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For County use only:
Received by:
Name Date
ACTIONS TAKEN:
Date Action