2. This form can be completed on this page and submitted when finished at the end, or the form can be printed, completed, and sent to:
   County Administrator's Office, 1100 Simonton Street, Suite 205, Key West, FL 33040, Phone: 305-292-4441, Fax: 305-292-4544
4. ADA/Human Resources Coordinator Contact:
   Alana Thurston, 1100 Simonton Street, Suite 268, Key West, FL 33040, email: thurston-alana@monroecounty-fl.gov, Phone: 305-292-4461, Fax: 305-292-4454
6. Additional assistance:
   Contact the County Administrator's Office by phoning 305-292-4441, between the hours of 8:30 a.m. - 5 p.m., if you are hearing or voice impaired, call "711."
8. REQUESTOR INFORMATION
10. First Name*
11. Last Name*
13. Address1*
15. City*
16. State*
17. Zip*
19. Email Address*
20. Phone
24. PERSON MAKING THE REQUEST (if other than individual needing the accommodation):
26. First Name
27. Last Name
29. Address1
31. City
32. State
33. Zip
35. Email Address
36. Phone
38. Other contact information:
42. INFORMATION ON ACCOMMODATION
44. Date and time accommodation is needed:*
46. Location accommodation is needed:*
48. Duration for which the accommodation is needed:*
50. Nature of disability that necessitates accommodation:
52. (Attach additional information or documentation if necessary)
54. Accommodations Requested: please check one of the following six options*

    1. Assistive listening device (work by increasing the loudness of sounds, minimizing background noise, reducing the effect of distance, and overriding poor acoustics with headphones.)
    2. Communication access real-time translation/transcription services (CART is a word-­for-word speech-to-text interpreting service for people who need communication access.)
    3. Sign language Interpreter (Specify American Sign Language, oral interpreter, signed English, or other type of signing system used by persons with hearing loss.)
    4. Assignment to a meeting room that is accessible to a person using a mobility device (Specify wheelchair, scooter, walker, or other mobility device that is used.)
    5. Provision of County documents in an alternative format (Specify Braille, large print, accessible electronic document, or other accessible format used by persons who are blind or have low vision)
    6. Other accommodation (Specify.)
56. Specify:
58. It is best practice to give consideration to the accommodation sought as required under title II of the ADA; however, alternative methods that achieve effective communication are permissible. The County may comply with the requirements of this section through such means as redesign of equipment, reassignment of services to accessible buildings, assignment of aides to beneficiaries, home visits, delivery of services at alternate accessible sites, alteration of existing facilities and construction of new facilities, use of accessible rolling stock or other conveyances, or any other methods that result in making its services, programs, or activities readily accessible to and usable by individuals with disabilities. The County is not required to make structural changes in existing facilities where other methods are effective in achieving compliance with this section. The County, in making alterations to existing buildings, shall meet the accessibility requirements of Regulation 35.151 in choosing among available methods for meeting the requirements of this section, the County shall give priority to those methods that offer services, programs, and activities to qualified individuals with disabilities in the most integrated setting appropriate. Auxiliary aid requests will be provided at no charge.
Leave This Blank:


70. 1. Receive an email copy of this form.
71. Email address

    This field is not part of the form submission.

72. Submit

* indicates a required field