Form CT811 "Reasonable Accommodation Request Form" - Connecticut

What Is Form CT811?

This is a legal form that was released by the Connecticut Department of Housing - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 28, 2016;
  • The latest edition provided by the Connecticut Department of Housing;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form CT811 by clicking the link below or browse more documents and templates provided by the Connecticut Department of Housing.

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Download Form CT811 "Reasonable Accommodation Request Form" - Connecticut

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CT811 Reasonable Accommodation Request Form
Reasonable Accommodation Fact Sheet
Notice of Your Right to a Reasonable Accommodation
If you are a person with disabilities and you need:
• A change in a policy, practice, or procedure that would give you an equal chance to access
the housing program and/or
• A change in the way we communicate with you or give you information,
you may ask for this kind of change, which is called a Reasonable Accommodation.
Note: If you require a Reasonable Accommodation pertaining to your access to a specific
housing property or unit, OR if you require a Reasonable Modification, i.e., a physical change to
the property or unit, please submit your request to the property’s Owner or Manager.
Your Request
Contact the Department of Housing to make a request for a Reasonable Accommodation. You
will be asked to complete the Request for a Reasonable Accommodation Form, which the
Department will use to track and verify your request. You only need to complete Page 2 of this
document. Notify staff if you need assistance in completing the form.
Verification of Need
You MAY be asked to allow us to verify that you are a person with disabilities, your need for this
accommodation, and the connection between your disabilities and the request.
Our Response
We will give you an answer within 14 days from the date of your request, unless we are unable
to obtain necessary information to process your request, or unless you agree to a longer time.
We will notify you if we need more information from you or if we would like to discuss other
ways we can meet your needs.
A request for a reasonable accommodation may be denied if providing the accommodation is
not reasonable, i.e., it would impose an undue financial and administrative burden on the
Department or it would fundamentally alter the nature of the housing program. If your request
is denied, we will explain the reasons in writing and you can provide us with more information,
if you think that will help. You may also appeal our decision.
Confidentiality
All information you provide will be kept confidential and will only be used to help us make a
determination. It is illegal for us to deny you any services or retaliate against you because you
made a Reasonable Accommodation Request.
How to Appeal a Decision
If you do NOT agree with our decision, you may submit your appeal in writing to: Department
nd
of Housing, Attn: Michael Santoro, 505 Hudson St 2
Floor, Hartford, CT 06106.
Page 1 of 3
Rev. 6/28/2016
CT811 Reasonable Accommodation Request Form
Reasonable Accommodation Fact Sheet
Notice of Your Right to a Reasonable Accommodation
If you are a person with disabilities and you need:
• A change in a policy, practice, or procedure that would give you an equal chance to access
the housing program and/or
• A change in the way we communicate with you or give you information,
you may ask for this kind of change, which is called a Reasonable Accommodation.
Note: If you require a Reasonable Accommodation pertaining to your access to a specific
housing property or unit, OR if you require a Reasonable Modification, i.e., a physical change to
the property or unit, please submit your request to the property’s Owner or Manager.
Your Request
Contact the Department of Housing to make a request for a Reasonable Accommodation. You
will be asked to complete the Request for a Reasonable Accommodation Form, which the
Department will use to track and verify your request. You only need to complete Page 2 of this
document. Notify staff if you need assistance in completing the form.
Verification of Need
You MAY be asked to allow us to verify that you are a person with disabilities, your need for this
accommodation, and the connection between your disabilities and the request.
Our Response
We will give you an answer within 14 days from the date of your request, unless we are unable
to obtain necessary information to process your request, or unless you agree to a longer time.
We will notify you if we need more information from you or if we would like to discuss other
ways we can meet your needs.
A request for a reasonable accommodation may be denied if providing the accommodation is
not reasonable, i.e., it would impose an undue financial and administrative burden on the
Department or it would fundamentally alter the nature of the housing program. If your request
is denied, we will explain the reasons in writing and you can provide us with more information,
if you think that will help. You may also appeal our decision.
Confidentiality
All information you provide will be kept confidential and will only be used to help us make a
determination. It is illegal for us to deny you any services or retaliate against you because you
made a Reasonable Accommodation Request.
How to Appeal a Decision
If you do NOT agree with our decision, you may submit your appeal in writing to: Department
nd
of Housing, Attn: Michael Santoro, 505 Hudson St 2
Floor, Hartford, CT 06106.
Page 1 of 3
Rev. 6/28/2016
CT811 Reasonable Accommodation Request Form
For DOH Agency Use Only
Client ID:
Applicant
Received:
Approved:
Participant
Verified:
Denied:
Applicant/Participant Request or a Reasonable Accommodation
I am an Applicant/Participant of the CT811 program and I claim to have a disability that limits
my ability to equally access the housing program.
Applicant/Participant’s Name:
Address:
Phone:
As a result of my disability, I am requesting the following Reasonable Accommodation(s):
☐ A change in a policy, practice or procedure: (Please specify)
☐ A change in the way I am communicated with or given information to: (Please specify)
Third-Party Verification
The following Third-Party Professional can verify my request. (List a Medical or Mental Health
Professional, which can include a Clinical Social Worker)
Professional’s Name:
Firm/Organization Name:
Address:
Phone Number:
Fax Number:
Authorization for the Release of Information
I authorize the State of Connecticut Department of Housing to contact the Third-Party
Professional listed above to verify that I am disabled, that I need this accommodation, and that
there is a connection between my disability and this request.
Signature: __________________________________________________ Date:
Page 2 of 3
Rev. 6/28/2016
CT811 Reasonable Accommodation Request Form
Verification
The Applicant/Participant that signed this form has requested a Reasonable Accommodation(s)
and has listed you as a Third-Party Professional who can verify this request. Please answer the
following questions
A. Do you believe the individual is someone with a physical or mental impairment that
substantially limits one or more major life activities, someone who has a record of such
an impairment, or someone regarded as having such an impairment?
☐ Yes
☐ No
☐ Cannot Verify
B. Do you believe the accommodation is necessary, is related to the person’s disability, and
will achieve its stated purpose?
☐ Yes
☐ No
☐ Cannot Verify
C. Is there any other information that would be helpful in making the appropriate
accommodation for this person? (Please do not discuss the person’s diagnosis or any
other information that is not directly relevant to the request for an accommodation.)
Name of Person Supplying the Information:
Title, Firm/Organization:
Signature: __________________________________________________ Date: ______________
WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make
willful, false statements of misrepresentation to any department or agency of the U.S. or to
any matter within its jurisdiction.
Page 3 of 3
Rev. 6/28/2016
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