Reasonable Modification Accommodation Request

Reasonable Modification Accommodation Request (TheHandi-Van)

All federally funded public transportation entities are subject to provide reasonable accommodations by making changes to policies, practices, and procedures if needed for an individual with a disability to use TheHandi-Van, unless providing such accommodations are an undue financial and administrative burden or constitute a fundamental alteration of the program or activity.

Please complete the form below if you are placing a reasonable modification accommodation request.

Contact Information

Date:	e.g. 07/10/2015
* First Name:
* Last Name:
* Address:
* City:
* State:	* Zip:
Phone No:	- - format: 808 123-1234
Email:	e.g. abc@domain.com
Please explain what policy or procedure is preventing you from using TheHandi-Van services: max 5000 characters characters left
Why is a modification needed in order to allow you to use TheHandi-Van services? max 5000 characters characters left
Signature:	Date Signed:
Note: Requests to accommodate a medical condition will require supporting documentation from a medical professional stating the barrier to using the service and the duration of the condition. You will receive a response to your request within 30 calendar days of receipt of your request.
* denotes required fields