REASONABLE ACCOMMODATION VERIFICATION

HOUSING AND COMMUNITY DEVELOPMENT

REASONABLE ACCOMMODATION VERIFICATION
(To be completed by Health Care Provider/Documenting Authority)
Head of Household:
Client No:
Re: Reasonable Accommodation Request
For:
(PRINT NAME OF HOUSEHOLD MEMBER FOR WHOM THE REQUEST IS BEING MADE)
Telephone:
PLEASE RETURN TO:
(Name of HCD Employee)
Address of HCD Employee:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone/Fax of Employee
Please enter a valid phone number.Format: (000) 000-0000.
THE FOLLOWING SECTION IS TO BE FILLED OUT BY THE DESIGNATED VERIFICATION SOURCE:
YESNO
2. Describe the problem(s) that the person is having with the HCD dwelling, building, property, practice, rule, policy, procedure, program or service:
3. Describe the type of change(s), feature(s) or assistance required:
4. Using the checklist on page 2 of 2, indicate the functional limitation(s) (i.e. the way major life activities are substantially limited) of the person for whom the accommodation is requested.
5. Please describe the relation between the person’s functional limitation(s) and the requested accommodation. Do not provide unnecessary details about the medical history or disabled status of the person seeking an accommodation.
Name of Medical Doctor:
(PRINT NAME OF MEDICAL DOCTOR)
Signature:

Clear
Date:

MonthDayYear
Date
Specify Specialty, if applicable:
License Practice #:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone:
Please enter a valid phone number.Format: (000) 000-0000.
Fax:
Please enter a valid phone number.Format: (000) 000-0000.

Rows	TYPE OF MAJOR LIFE ACTIVITIES (Check applicable)	DISABILITY STATUS D= Disabled* (or) ND= Not Disabled (Enter D or ND as applicable)
Walking
Standing
Climbing
Bending
Stooping
Kneeling
Use of Hands
Reaching
Self-Care
Speaking
Breathing
Seeing
Hearing
Lifting
Intelligence (a person’s capacity for understanding)
Thinking (the ability to form or conceive in the mind)
Perception (the brain’s interpretation of internal and external stimuli)
Judgment (the ability to assess a given situation and act appropriately)
Mood (emotional tone underlying the behavior)
Behavior (specifically examining behavior that is disruptive, distressing or aggressive)
Other (Please Specify in non-technical terms that simply describe what the client cannot do or has difficulty doing)
MEDICAL DOCTOR/VERIFICATION SOURCE INFORMATION
NOTES (use additional sheet if necessary):

HOUSING AND COMMUNITY DEVELOPMENT