Request for Reasonable Accommodation or Modification

Your Name *

Email Address *

Your Address

City

State WisconsinAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew_HampshireNew_JerseyNew_MexicoNew_YorkNorth_CarolinaNorth_DakotaOhioOklahomaOregonPennsylvaniaRhode_IslandSouth_CarolinaSouth_DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest_VirginiaWyoming

Zip Code

Daytime or Cell Phone

Program, service or event for the request *

 

Location of program, service or event *

 

Date of program, service or event (Enter as MM/DD/YYYY) *

I am requesting the following accommodation or modification.  *
To select multiple options, hold down the Shift key as you click one or more listed option.
Wheelchair AccessASL Interpretation ServicesPrinted Material in Alternate FormatModification of Policy or ProceduresPrinted Material (Please indicate desired format type below)Other (Please describe below)

If you selected "Printed Material" as your accommodation or modification, in the previous question, please describe the material and desired format type:

(Please provide a week advance notice for requests of printed materials in Braille.)

If you selected "Other" as your accommodation or modification, in the previous question, please describe your request:

Please provide any additional details necessary to process this request:

The ADA Coordinator or department representative will contact you about your request. If you have any questions or concerns, please contact the ADA Coordinator at:

Jason Ostrowski , ADA Coordinator

City of Milwaukee
Department of Administration
Office of Equity and Inclusion
200 East Wells Street, Room 603
Milwaukee, WI 53202

Phone: (414) 286-3475
TTY: 711
Fax: (414) 286-5475
Email: [email protected]

If you wish to print and send in the form, you may download a printable Request Form.