Approved,  SCAO

Original - Administrative court file
Copy - Applicant

REVIEW  OF  REQUEST  FOR
REASONABLE  ACCOMMODATIONS  AND  RESPONSE

Court name and address

Telephone number of ADA coordinator:

If your request for accommodations was denied, you can ask for a review of your request.  Complete the Applicant section below.
Enter the date and sign your name.  Mail or give your completed request to the ADA Coordinator.  If you need help completing this
form, contact the ADA coordinator at the above telephone number.

APPLICANT  INFORMATION (to be kept confidential)

Applicant  is

Witness

Juror

Attorney

Party

Other  (specify)

Case name and number (if applicable)

Name

Address

City

E-mail address

State

Zip

Telephone no.

1. What type of proceeding or court service, activity, or program are you attending (i.e., hearing, jury duty, mediation meeting, trial)?

2. On what dates do you need accommodations?

4. What type of accommodations do you need?

3. For what impairment do you need accommodations (for a sign language interpreter, specify ASL, CDI, or CART)?

Date

Applicant  signature

RESPONSE TO REQUEST

The request is GRANTED

for the above matter or appearance,

from

in whole as follows: (specify the accommodations)

to

,

for an indefinite period,

in part.  As consented to by the applicant, alternative accommodations are as follows:  (specify the accommodations)

The request is DENIED because

the applicant is not a qualified individual with a disability under the ADA.
the request creates an undue financial or administrative burden on the court (as defined by the ADA).
the request fundamentally alters the nature of the service, program, or activity (as defined by the ADA).

The basis for this denial is:  (Specify on separate sheet if needed.  Include alternative accommodations offered but rejected by the applicant.)

Date

Judge

Bar no.

NOTE:  If your request is denied, you may submit a written request for review by the State Court Administrator.  Send your request
to the State Court Administrative Office, State Court Administrator, Michigan Hall of Justice, PO Box 30048, Lansing, MI 48909.

Court Use Note:  This completed and signed Review of Request for Reasonable Accommodations and Response must be maintained with the original Request
in a confidential administrative file.

MCL 393.501 et seq., 42 USC 12111 et seq.

MC 70a   (10/15)   REVIEW OF REQUEST FOR REASONABLE ACCOMMODATIONS AND RESPONSE