ReasonableAccommodation_Verification

Verification of Handicap / Disability for Purpose of Determining Reasonable Accommodation / Modification Needs

[{"type":"date","required":true,"label":"Date:","name":"Todays-date","className":"col-md-6 col-lg-3"},{"type":"text","required":true,"label":"To:","placeholder":"List name and address of medical or mental health professional being requested to provide information","name":"To","className":"d-block","subtype":"text"},{"type":"text","required":true,"label":"Phone Number:","placeholder":"List phone number; area code first","name":"Phone-Number-","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Fax Number:","placeholder":"List fax number, area code first","name":"Fax","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"Name of Resident / Applicant requesting Reasonable Accommodation / Modification: ","className":"d-block"},{"type":"text","required":true,"label":"Name: ","placeholder":"Full name","name":"Name","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Birth: ","name":"date-of-birth","className":"col-lg-4"},{"type":"text","required":true,"label":"Address:","placeholder":"Street, City, State, Zip Code","name":"Address","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"The person named above has requested an accommodation or modification under a program funded by the U.S. Department of Housing and Urban Development (HUD). HUD requires Spartanburg Housing (SH) to verify all the information that is used in determining this person’s level of benefits. We ask for your cooperation in providing the following information and faxing it to the ADA Coordinator for Spartanburg Housing at 864-598-6154. Your prompt return of this information will help to ensure timely processing of the application for assistance. The applicant/resident has consented to this release of information. An individual with handicaps means any person who has physical or mental impairment that substantially limits one or more major life activities; has a record of such an impairment; or is regarded as having such an impairment. For purposes of employment, this term does not include: Any individual who is an alcoholic or drug abuser whose current use of alcohol or drugs prevents the individual from performing the duties of the job in question, or whose employment, by reason of current alcohol or drug abuse, would constitute a direct threat to property or the safety of others; or any individual who has a currently contagious disease or infection and who, by reason of such disease or infection, would constitute a direct threat to the health or safety of other individuals or who, by reason of the currently contagious disease or infection, is unable to perform the duties of the job. For purposes of other programs and activities, the term does not include any individual who is an alcoholic or drug abuser whose current use of alcohol or drugs prevents the individual from participating in the program or activity in question, or whose participation, by reason of such current alcohol or drug abuse, would constitute a direct threat to property or the safety of others. As used in this definition, the phrase: (a) Physical or mental impairment includes:(1) Any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: Neurological; musculoskeletal; special sense organs; respiratory, including speech organs; cardiovascular; reproductive; digestive; genital-urinary; hemic and lymphatic; skin; and endocrine; or(2) Any mental or psychological disorder, such as mental retardation, organic brain syndrome, emotional or mental illness, and specific learning disabilities. The term physical or mental impairment includes, but is not limited to, such diseases and conditions as orthopedic, visual, speech and hearing impairments, cerebral palsy, autism, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, diabetes, mental retardation, emotional illness, drug addiction and alcoholism. (b) Major life activities mean functions such as caring for one's self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning and working. (c) Has a record of such an impairment means has a history of, or has been misclassified as having, a mental or physical impairment that substantially limits one or more major life activities. (d) Is regarded as having an impairment means:(1) Has a physical or mental impairment that does not substantially limit one or more major life activities but that is treated by a recipient as constituting such a limitation.(2) Has physical or mental impairment that substantially limits one or more major life activities only as a result of the attitudes of others toward such impairment; or(3) Has none of the impairments defined in paragraph (a) of this section but is treated by a recipient as having such an impairment. The term does not include any individual who is an alcoholic or drug abuser whose current use of alcohol or drugs prevents the individual from participating in the program or activity in question, or whose participation, by reason such current alcohol or drug abuses, would constitute a direct threat to property or the safety of others.","className":"d-block"},{"type":"radio-group","required":true,"label":"Based on the definition above, it is my professional opinion that the person named on this release is: ","inline":true,"name":"Determination","className":"d-block","values":[{"label":"Handicapped / Disabled","value":"option-1"},{"label":"Not Handicapped / Disabled","value":"option-2"}]},{"type":"paragraph","subtype":"p","label":"If handicapped / disabled has been marked, and the handicap / disability is expected to last LESS than a lifetime, please estimate the date that the accommodation or modification in housing will no longer be required: ","className":"d-block"},{"type":"date","label":"End date: ","name":"End-Date","className":"col-md-6 col-lg-3"},{"type":"radio-group","required":true,"label":"Please select the specific accommodations or modifications in housing that are required due to this person's handicap / disability:  (select all that apply)","description":"Select all that apply","inline":true,"name":"Required-accommodations-or-modifications","other":true,"className":"d-block","values":[{"label":"Handicap parking space","value":""},{"label":"Ramp to unit","value":""},{"label":"(504) Wheelchair accessible unit","value":""},{"label":"Maximum mobility distance","value":""},{"label":"Shower / Tub grab bar","value":""},{"label":"Grab bar at commode","value":""},{"label":"Handicap commode","value":""},{"label":"Separate sleeping room ","value":""},{"label":"Lighted Door bell","value":""},{"label":"Strobe smoke detector","value":""},{"label":"Brighter lighting","value":""},{"label":"Ceiling fan in bedroom(s)","value":""},{"label":"Additional room for medical equipment","value":""},{"label":"Lever door knobs","value":""},{"label":"32\" doorways","value":""},{"label":"Motion sensor porch light","value":""},{"label":"Door bell","value":""},{"label":"Service animal","value":""},{"label":"Companion animal","value":""},{"label":"Live-in aide must complete live-in aide form","value":""}]},{"type":"paragraph","subtype":"p","label":"<div class=\"clear\"></div>","className":"d-block"},{"type":"text","required":true,"label":"Name / Title of medical or mental health professional","placeholder":"Full name / Title","name":"3rd-party-signature","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Organization / Medical Facility / Agency","placeholder":"Agency name","name":"Agency","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Signature","name":"Signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date ","name":"Date","className":"col-lg-4"}]

ReasonableAccommodation_Verification

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