Cdcr 1824 Form – Fill Out and Use This PDF

STATE OF CALIFORNIA

DEPARTMENT OF CORRECTIONS AND REHABILITATION

NOTE: THIS FORM IS TO BE USED ONLY BY INMATES/PAROLEES WITH DISABILITIES

In processing this request, it will be verified that the inmate/parolee has a disability which is covered under the Americans With Disabilities Act.

In accordance with the provisions of the Americans With Disabilities Act (ADA), no qualified individuals with a disibility shall, on the basis of disability, be excluded from participation in, or be denied the benefits of the services, activities, or programs of a public entity, or be subjected to discrimination.

You may use this form to request specific reasonable modification or accommodation which, if granted, would enable you to participate in a service, activity or program offered by the Department/institution/facility, for which you are otherwise qualified/eligible to participate.

Submit this completed form to the institution or facility's Appeals Coordinator's Office. A decision will be rendered within 15 working days of receipt at the Appeals Coordinator's Office and the completed form will be returned to you. If you do not agree with the decision on this form, you may pursue further review. The decision rendered on this form constitutes a decision at the FIRST LEVEL of review.

To proceed to SECOND LEVEL, attach this form to an Inmate/Parolee Appeal Form (CDC 602) and complete section "F" of the appeal form.

Submit the appeal with attachment to the Appeals Coordinator's Office within 15 days of your receipt of the decision rendered on this request form.

If you are not satisfied with the SECOND LEVEL review decision, you may request THIRD LEVEL review as instructed on the CDC 602.

MODIFICATION OR ACCOMMODATION REQUESTED

DESCRIPTION OF DISABILITY:

WHAT VERIFICATION DO YOU HAVE OF YOUR DISABILITY?

DESCRIBE THE PROBLEM:

WHAT SPECIFIC MODIFICATION OR ACCOMMODATION IS REQUESTED?

_______________________________________	_________________________
INMATE/PAROLEE'S SIGNATURE	DATE SIGNED

REASONABLE MODIFICATION OR ACCOMMODATION REQUEST			Page 2 of 2
CDCR 1824 (Rev. 10/06)
	REVIEWER'S ACTION
		DATE ASSIGNED TO REVIEWER:
TYPE OF ADA ISSUE		DATE DUE:

PROGRAM, SERVICE, OR ACTIVITY ACCESS (Not requiring structural modification)

Auxiliary Aid or Device Requested

Other__________________________________________________________

PHYSICAL ACCESS (requiring structural modification)

DISCUSSION OF FINDINGS:

________________________________________	________________________________________
DATE INMATE/PAROLEE WAS INTERVIEWED	PERSON WHO CONDUCTED INTERVIEW

DISPOSITION
	GRANTED	DENIED	PARTIALLY GRANTED
BASIS OF DECISION:

NOTE: If disposition is based upon information provided by other staff or other resources, specify the resource and the information provided. If the request is granted, specify the process by which the modification or accommodation will be provided, with time frames if appropriate.

APPROVAL

DATE RETURNED TO INMATE/PAROLEE