Accommodation Request Form

Note: For a fillable version please download the ADA Accommodation Request Form to you computer. The document is in Adobe Acrobat (pdf) format so you must download the form and use Adobe Acrobat Reader to properly view and fill out this document.

AMERICANS WITH DISABILITIES ACT
REASONABLE ACCOMMODATION REQUEST FORM

Name: *

Phone: *

Email: *

If employed by Knox County, please list your department:

If not employed by Knox County, what facility, program, activity or service do you need assistance with? (check all that apply)

Court

Public Building

Parks

Other:

1. What specific accommodation are you requesting?

2. If you are not sure what accommodation is needed, do you have any suggestions about what options we can explore?

3. Is your accommodation time sensitive?

Yes

If yes, please explain:

4. Have you had any accommodations in the past for this same limitation?

Yes

If yes, what were they and how effective were they?

5. Please provide any additional information that might be useful in processing your accommodation request:

Signature: *

Date: *

Need Assistance with this form?
Text 865-318-9310 or
TTY 865-215-2497

Risk Management

Carly Pearson, ADA Coordinator
City County Building
400 Main St, Suite 345
Knoxville, TN 37902
865-215-3603
865-318-9310

Marcus Kennedy, Organizational Development Director
400 Main Street, Suite 345
Knoxville, TN 37902
865-215-4427

Text 865-318-9310 or
TTY 865-215-2497

Accommodation Request Form

ADA

Accommodation Request Form

AMERICANS WITH DISABILITIES ACT REASONABLE ACCOMMODATION REQUEST FORM

Risk Management

AMERICANS WITH DISABILITIES ACT
REASONABLE ACCOMMODATION REQUEST FORM