Accessibility Accommodation Request

The Library provides accommodations by request for physical access, communications or other needs to ensure services, activities and programs are available to people with disabilities. To request an accommodation, please fill out the Reasonable Accommodation Request Online Form below or download and print the PDF version of the form and return it to the library.

The Derby Public Library seeks to provide reasonable accommodations for physical access, communications, or other needs to ensure that services, activities, and programs are available to individuals with disabilities.

Please make arrangements no later than 14 business days prior to the program. Your request will be addressed as expeditiously as possible. Certification by a Health Care Provider may be required. If you feel your request or concern has not been addressed appropriately, you may appeal to the Library Board in writing.

Accessibility Accommodation Request Form

Name *

First

Last *

Last

Address *

Phone

Cell Phone (optional)

Email *

What service program or activity does this request concern? *

What is the disability that makes an accommodation(s) necessary? (specify) *

What accommodation(s) are you requesting? (specify) *

Assistive equipment (please describe equipment you are requesting be provided): *

Please provide any additional information that might be helpful in processing your accommodation(s) request. *

Type your name here to certify that the above information is true. *

The Americans with Disabilities Act (“ADA”) does not require The Derby Public Library to take any action that would fundamentally alter the nature of its programs or services, or impose an undue financial or administrative burden.

This form is for Library use only and the information will be kept confidential.

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Approved by the Derby Public Library Board of Directors February 27, 2019

Accessibility Accommodation Request

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