[Suffolk County, NY] REQUEST FOR REASONABLE ACCOMMODATION

SUFFOLK COUNTY DEPARTMENT OF SOCIAL SERVICES

REQUEST FOR REASONABLE ACCOMMODATION

Full Name

Phone Number

Program Division

The activity, program or service for which a reasonable accommodation is requested:

Date of request for reasonable accommodation:

Is your accommodation request time sensitive? If yes, please explain:

Accommodation Requested – Be as specific as possible, e.g. adaptive equipment, reader, interpreter:

Reason for Request – Be as specific as possible:

Request for Additional Information – Please provide any additional information that might be useful in processing your request (you may attach any supporting documentation to your request):

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ADA 6 Request for Reasonable Accommodation (Rev. 3/22)