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Reasonable Accommodation Request Form

Steps

  1. 1. Step One
  2. 2. Person Making Request (if different from person needing accommodation / modification)
  3. 3. Reasonable Accommodation Request Details
  • Step One

    1. Notice - Please Contact the MRCOG Title VI Coordinator:
      -- For further assistance, if information is needed in another language, if you need assistance in completing this form, need the form in an alternative format (such as a larger font), or need to submit the form in an alternative format (such as a personal interview or by audio recording).
    2. -- If you are deaf or hard of hearing and are requesting an interpreter, please specify the type of interpreter (i.e., American Sign Language (ASL), signed English, Communication Access Real Time Translation (CART), or other) when describing the accommodations you are requesting.
    3. -- If you do not want to send an electronic request, contact the Title VI Coordinator, or submit the information in writing via US Postal Service to the Mid-Region Council of Governments, 809 Copper Avenue NW, Albuquerque, NM 87102.
    4. Contact the MRCOG Title VI Coordinator
      Sandra Gaiser, Title VI Coordinator, at 505-247-1750 or sgaiser@mrcog-nm.gov.
    5. Requestor's Information
    6. Preferred Method of Contact: