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Canton Township Request for ADA Accommodation (11.27.18)

2. Date and Time
   Date and Time

   Date and Time
4. First Name*
5. Last Name*
7. Email Address*
9. Address1*
11. Address2
13. City
14. State
15. Zip
17. Primary Contact Number*
19. Alternate Phone Number (Optional)
21. Best Time To Call
23. Is this request for a minor child?
25. If yes, how old is the minor?
27. Type of Accommodation(s)*

    Please select all types of accommodation(s) that apply

    1. Mobility - Sidewalks
    2. Parking - Accessibility
    3. Programming - Leisure Services (i.e. access to recreation classes)
    4. Programming - General Government (i.e. access to public meetings)
    5. Access to Township Facilities
    6. Access to Township Materials or Data
    7. Auxiliary Aids or Services
    8. Canton Township Employee - Service Animal Registration
    9. Translation Services (Provide detail i.e. English to Arabic)
    10. Other (Please provide as much detail as possible)
29. Accommodation Description *
    Please describe the nature of the accommodation(s) being requested. Please provide as much detail as possible, including: specific location, meeting date and time, and class information.
33. Is your accommodation request time sensitive? *

    1. Yes
    2. No
35. The requester will be contacted within four business days by appropriate Canton Township staff.
    Canton Township will send email confirmation that your request has been received and is being reviewed within four business days of receiving your request. If you do not receive confirmation that Canton Township received your request for accommodation please contact Human Resources directly at 734-394-5260 to verify the request went through. Reasonable accommodations can be made with advance notice. Contact Human Resources directly at 734-394-5260 if the accommodation request is needed within four business days.
37. Legal Signature *

    I acknowledge that the information provided is accurate and complete.

    1. I agree
39. Requester's Electronic Signature
    Please type full name.
41. Canton Township ADA Contact Information

    Barb Brouillette, Interim ADA Compliance Coordinator, 1150 S. Canton Center Road, Canton, MI 48188, (734) 394-5260

43. Log Number
44. Date Received
    Date Received

    Date Received
46. Assigned To Responsible Department Designee

    1. Mobility/Sidewalks - Erika Hildago
    2. Parking Accessibility - Gregg King
    3. Programming/Leisure Services - Jon LaFever
    4. Programming/General Government - Michael Siegrist
    5. Access To Township Facilities - Gregg King
    6. Access To Township Materials or Data - Michael Siegrist
    7. Auxiliary Aids or Services - Barb Brouillette
    8. Other - Barb Brouillette
    9. Summit - Jason Lambardo
48. Date Forwarded To Designee
    Date Forwarded To Designee

    Date Forwarded To Designee
50. Accommodation Request Status
    Please provide details regarding accommodation(s) status - pending approval or denial.
52. Status of Accommodation(s) Request*

    Select One of the following

    1. Approved as specifically requested
    2. Approved with modifications
    3. Pending - Resources
    4. Denied - Unable to make a reasonable accommodation
54. Reason(s) for Denial of Accommodation Request(s)
    Detailed reason(s) for denial of request
56. Date Processed
    Date Processed

    Date Processed
58. Communications with Requester
60. Any Additional Comments or Consideration
62. Status of Alternative Accommodation(s)

    1. Alternative Accommodation(s) Accepted
    2. Alternative Accommodation(s) Rejected

    If an alternative accommodation was presented, indicate acceptance or rejection
64. Closed Out Date
    Closed Out Date

    Closed Out Date
Leave This Blank:


66. 1. Receive an email copy of this form.
67. Email address

    This field is not part of the form submission.

68. Submit Submit and Print

* indicates a required field