Public Accommodation Request

Do you need a housing accommodation?

Do you need a housing accommodation? Yes Do you need a housing accommodation? no

Do you use a wheelchair?(Required) *

Do you use a wheelchair? Yes Do you use a wheelchair? no

Do you need vision related accommodations?

Do you need vision related accommodations? Yes Do you need vision related accommodations? no

Check all you use

Screen Reader Capable/ Electronic Files
Braille
Enlarged Print
Other

Do you need deaf/hard of hearing accommodations?

Do you need deaf/hard of hearing accommodations? Yes Do you need deaf/hard of hearing accommodations? no

Check any you use

Sign Language
Hearing Aids
Lip Reading
Interpreters
Other

Do you currently take medications related to this request?

Do you currently take medications related to this request? Yes Do you currently take medications related to this request? no

Are you receiving assistance from any of these providers?

Please check all that apply.

Dept of Human Services Division of Rehabilitation Services
Veterans Administration
Other Agencies