Accommodation Request Form

Barry-Eaton District Health Department (BEDHD) provides reasonable accommodations, by request, for physical access, communications, or other needs to ensure services, activities, and programs are available. Please complete the following form regarding your accommodation request. Alternative formats are available as needed— please specify the format you prefer.

Name Name * First Last
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone * - ### - ### ####
Email
Preferred Method of Contact (type and time of day) *
Preferred Communication Format *
Program/Service/Activity Requesting *
Describe the accommodation you are requesting below, when it is needed, and how it will assist you in your use of BEDHD activities, programs, or services. *
Please direct questions to:

Rebekah Condon, MPH
Operations Manager
Barry-Eaton District Health Department
1033 Health Care Dr. Charlotte, MI 48813
517-543-2694
rcondon@bedhd.org

Your request will be addressed as quickly as possible. However, you will be contacted in writing no later than 15 calendar days after receipt of the request form. The process for finalizing an accommodation request may vary slightly depending on the nature of the request, the duration of the desired accommodation, and the number of locations involved in the request. Additional information may be requested. BEDHD’s response to accommodation requests shall be in writing, and when needed, in the format requested. Appeals of accommodation request decisions should be directed to the Health Officer, Colette Scrimger at 517-543-2602 within 15 calendar days of receiving the response.

Accommodation Request Form

Accommodation Request Form

Please direct questions to: Rebekah Condon, MPH Operations Manager Barry-Eaton District Health Department 1033 Health Care Dr. Charlotte, MI 48813 517-543-2694 rcondon@bedhd.org

Please direct questions to:

Rebekah Condon, MPH
Operations Manager
Barry-Eaton District Health Department
1033 Health Care Dr. Charlotte, MI 48813
517-543-2694
rcondon@bedhd.org