Ada accommodation request form pdf 2025

1. Click ‘Get Form’ to open the ADA Accommodation Request Form in the editor.
2. Begin by filling in the date, Cal/Manager Code, Unit No., and Reg./Client No. at the top of the form. This information helps identify your request.
3. In the section labeled 'Person requesting the accommodation', provide your full name and sign where indicated. Ensure that you include the date of your signature.
4. Clearly state your requested accommodation in the designated area. Be specific about what you need to ensure equal access.
5. If applicable, have a health care provider complete the certification of disability section. They will need to confirm whether you meet the definition of disability and explain how it relates to your accommodation request.
6. Complete the connection (nexus) section by answering how your requested accommodation links to your disability and how it allows equal benefit from HACLA’s program.
7. Finally, ensure that a health care provider signs and provides their title, print name, date, phone number, and license number or agency name before submitting.

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