"Inmate Ada Request Routing Form" - Montana

Inmate Ada Request Routing Form is a legal document that was released by the Montana Department of Corrections - a government authority operating within Montana.

Form Details:

  • Released on March 26, 2015;
  • The latest edition currently provided by the Montana Department of Corrections;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Montana Department of Corrections.

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Download "Inmate Ada Request Routing Form" - Montana

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MONTANA DEPARTMENT OF CORRECTIONS
INMATE ADA REQUEST ROUTING FORM
Offender Name: ______________________________________ Offender Number: ___________
(Last)
(First)
Facility: _____________________________________________ Unit: ______________________
Date Request Received by Inmate ADA Coordinator: ______________________
Type of Request: ______________________________________________
Please follow steps in numbered order.
1. Inmate ADA Coordinator
Is the request and/or concern an ADA issue?
Yes (develop proposed plan and proceed with step number 2)
No (inform offender that his/her request is not an ADA issue)
What disciplines does the request affect during the course of investigation?
Medical
Security
Warden
Legal
Other: ________________
Proposed Plan:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Date submitted to Clinical Services Division Administrator: ______________________________
Signature: ________________________________________
Date: ______________________
(Inmate ADA Coordinator)
2. Clinical Services Division Administrator
Proceed with Proposed Plan
Proceed with Alternative Plan
Do Not Proceed
Comments:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Signature: ________________________________________
Date: ______________________
(Clinical Services Division Administrator)
Clinical Services Division
03/26/2015
MONTANA DEPARTMENT OF CORRECTIONS
INMATE ADA REQUEST ROUTING FORM
Offender Name: ______________________________________ Offender Number: ___________
(Last)
(First)
Facility: _____________________________________________ Unit: ______________________
Date Request Received by Inmate ADA Coordinator: ______________________
Type of Request: ______________________________________________
Please follow steps in numbered order.
1. Inmate ADA Coordinator
Is the request and/or concern an ADA issue?
Yes (develop proposed plan and proceed with step number 2)
No (inform offender that his/her request is not an ADA issue)
What disciplines does the request affect during the course of investigation?
Medical
Security
Warden
Legal
Other: ________________
Proposed Plan:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Date submitted to Clinical Services Division Administrator: ______________________________
Signature: ________________________________________
Date: ______________________
(Inmate ADA Coordinator)
2. Clinical Services Division Administrator
Proceed with Proposed Plan
Proceed with Alternative Plan
Do Not Proceed
Comments:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Signature: ________________________________________
Date: ______________________
(Clinical Services Division Administrator)
Clinical Services Division
03/26/2015
3. Inmate ADA Coordinator
Revise proposed plan to align with Clinical Services Division Administrator comments
Revised Plan:
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Signature: ________________________________________
Date: ______________________
(Inmate ADA Coordinator)
4. Review From Applicable Disciplines
* If request needs to be presented to the Warden Management Team, the Clinical Services Division
Administrator or designee will present the proposal.
Medical: ____________________________
Initials: _________ Date: _________ Comments: ______________________________
Security: ____________________________
Initials: _________ Date: _________ Comments: ______________________________
Warden: _____________________________
Initials: _________ Date: _________ Comments: ______________________________
Legal: ______________________________
Initials: _________ Date: _________ Comments: ______________________________
Other: ______________________________
Initials: _________ Date: _________ Comments: ______________________________
5. Clinical Services Division Administrator
Approved
Not Approved
Comments:
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Signature: ________________________________________
Date: ______________________
(Clinical Services Division Administrator)
6. Inmate ADA Coordinator
Proposal has been approved by Clinical Services Division Administrator and/or other
disciplines (if applicable); proceed with resolution.
* In addition to this form, save the response letter, original request form and all other
pertinent documentation for record keeping.
Proposal has not been approved by Clinical Services Division Administrator and/or other
disciplines (if applicable); do not proceed.
Signature: ________________________________________
Date: ______________________
(Inmate ADA Coordinator)
Clinical Services Division
03/26/2015
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