Request for Reasonable Accommodation

Please Fill out and submit this form to request accommodation for Ecology program’s services, or activities. You may call 360-407-7668 for assistance with this form. Persons with impaired hearing may call Washington Relay Service at 711. Persons with speech disability may call TTY at 877-833-6341.

Contact: Hanna Waterstrat, Ecology ADA Coordinator, 360-407-7668, hanna.waterstrat@ecy.wa.gov.


WRITTEN MATERIALS (PRINTED OR ONLINE)

Do you know the title(s) of the specific publication(s) you want? Yes     No
If yes, please provide the title(s)

If no, please provide the information below to the best of your ability.

What alternate format do you prefer?

Large print
Reader
Braille
Digital format (please specify below)

Other (please specify below)

MEETINGS OR EVENTS

Name of meeting or event:

Date scheduled:

Do you need a reader? Yes     No

Do you need a sign language interpreter? Yes     No

If yes, specify preference:
Visual     Tactile

Do you have other communication requests? Yes     No

If yes, please specify:

Transcripts
Video displays
Captioning
Assistive listening device
Induction Loop
Other (please specify below)

REQUESTOR INFORMATION

How may we contact you?

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