Accommodation Request Form

Date of Request

Name

Best Means of Contacting (check one)

Mail

Telephone

E-mail

Best Time for Contacting

Address

City

State

Zip Code

Telephone Number

Telephone Type

Voice

TDD

E-mail

1. Please describe the accommodation(s) you are requesting. If there is more than one accommodation that you believe will meet your needs, please describe all possible accommodations.

2. Please describe the reason(s) why you are requesting an accommodation. If applicable, explain how the requested accommodation(s) will enable you to participate in IEPA services and activities.

3. Are you requesting a one-time accommodation? If so, please provide the following information.

Yes

Occasion that requires accommodation

Start Date

Start Time

Address (of event)

City, State & Zip Code (of event)

If a continuous accommodation is needed: Please identify how long will the requested accommodation(s) be needed.

4. Please provide information that you believe supports your need for the requested reasonable accommodation. Please also provide any other information that you believe is relevant to your request.

Attachments

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