Compliance with Equal Opportunity Program Reasonable Accommodations Procedures and Policies 15-23 Change 1

GST MICHIGAN WORKS! POLICY 15-23 Change 1

TO: Chief Executive of Subrecipients and Agency Staff

FROM: Jody Kerbyson, CEO

SUBJECT: Compliance with Equal Opportunity Program Reasonable Accommodations Procedures and Policies

EFFECTIVE: April 1, 2017

PROGRAMS: These Reasonable Accommodations Procedures apply to all programs that are administered by GST Michigan Works! Agency (MWA), and that are operated by the MWA’s subrecipient network.

REFERENCES:

GST Michigan Works! Equal Opportunity Policy Guide
American With Disabilities Act (ADA) of 1990, Public Law 101-336.
Americans with Disabilities Act Amendments Act (ADAAA) of 2008
Michigan Persons with Disabilities Civil Rights Act of 1976, Public Act 220.
Section 504 of the Rehabilitation Act of 1973.
29 CFR Part 32, Implementation of Section 504 with respect to programs and activities receiving or beneﬁting from federal ﬁnancial assistance.
29 CFR Part 38, Workforce Innovation and Opportunity Act (WIOA) Section

188 and other sections relevant to Equal Opportunity Program Accessibility.

Regulations implementing workforce programs.

RESCISSIONS: PI 15-23

PURPOSE: To outline provisions that prohibit exclusions and protect qualiﬁed individuals with disabilities from discrimination in services and program activities, and in access to facilities and employment opportunities.

POLICY: GST Michigan Works! and its subrecipient network are committed to providing equal access to workforce development services and training opportunities, and to facilities and employment opportunities. It is the policy of the MWA and its subrecipient network to provide reasonable accommodations to ensure that qualiﬁed individuals with disabilities have equally effective opportunities to participate in, and to enjoy the beneﬁts of the programs, services, activities, facilities and employment opportunities that are provided through the local workforce system.

SCOPE OF REASONABLE ACCOMMODATION COVERAGE

The MWA and its subrecipient network will make reasonable accommodations to the known physical or mental limitations of eligible and otherwise qualiﬁed individuals with disabilities,

unless it can be shown that the accommodation would impose an undue hardship.

Further the MWA and its subrecipient network will make reasonable modiﬁcations to policies, practices or procedures where necessary to avoid discrimination on the basis of disability, unless such modiﬁcations would fundamentally alter the nature of the program, activity, or service.

Reasonable Accommodation Provisions for Applicants and Participants/Registrants

The scope of reasonable accommodation coverage for applicants and participants/ registrants includes provisions for:

Modifying local procedures, as necessary, to ensure that an

accommodation request can be made;

Restructuring job or training programs;
Developing modiﬁed work or training schedules;
Altering assessment/testing techniques which prevent the fair

evaluation of skills;

Providing auxiliary aids and services;
Acquiring or modifying equipment or devices; and
Making necessary alterations to the work or training site to ensure

that facilities are accessible to individuals with disabilities.

Reasonable Accommodation Provisions for Employees/Applicants for Employment

The scope of reasonable accommodation coverage for employees/applicants for employment includes provisions for:

Modifying local procedures as necessary, to ensure that

accommodation requests can be made;

Modifying the job application process;
Restructuring job or employment-related training programs;
Developing modiﬁed work schedules;
Altering assessment/testing techniques which prevent the fair evaluation of skills;
Providing auxiliary aids and services;
Acquiring or modifying equipment or devices;
Making necessary alterations to the work site to ensure that facilities are

accessible to individuals with disabilities; and

Implementing changes that enable an employee with a disability to enjoy equal beneﬁts and privileges of employment.

Reasonable Accommodation Provisions for the General Public

The scope of reasonable accommodation coverage for the general public includes provisions for:

Modifying agency practices, as necessary, to ensure that an

accommodations request can be made;

Providing auxiliary aids and services;
Acquiring or modifying equipment or devices;
Providing notiﬁcation of the process individuals with disabilities are to follow to request accommodations needed to access the services and activities of, or employment with, or to enjoy the beneﬁts provided by, the MWA and its service provider network to members of the general public who are not persons with

disabilities.

REASONABLE ACCOMMODATION PROCEDURES

Procedures for Requesting an Accommodation

An individual with a disability is responsible for requesting accommodation. Each accommodation request will be evaluated on a case-by-case basis, taking into consideration the requestor’s abilities and limitations due to disability and the essential functions associated with the activity, training, program, service, facility, or employment opportunity the person is seeking to access.

Individuals, including applicants/ participants/ registrants, employees/ applicants for employment, and the general public, who request reasonable accommodation must:

Identify himself/ herself as a person with a disability who is in need of accommodation;

Complete the appropriate GST Reasonable Accommodation Request Form, which is attached to this document, or make a verbal request, within 182 calendar days after the employee or individual knew or reasonably should have known that an accommodation was needed;

Submit the completed form or verbally make his/ her request to the designated MWA representative or MWA Equal Opportunity Manager (EOM).

Provide (or help to obtain) applicable medical documentation and clarifying information for review and processing, if the MWA, its subrecipient, or another applicable entity requests it. (NOTE: Failure to provide medical documentation, when requested, could result in the denial of reasonable accommodation.)

Participate in assessing accommodation options.

Conﬁdentiality of Medical Disclosures/Records

Disability disclosures and all information concerning the presence or nature of a disability and/ or the medical condition or history of applicants, participants, registrants, employees, applicants for employment, or members of the general public, including information voluntarily disclosed, will be treated as conﬁdential medical information. Steps will be taken to guarantee the security of medical records and to ensure that such information is not included in an employee’s personnel ﬁle or a participant’s/applicant’s ﬁle.

All information regarding the presence or nature of a disability will be treated as a conﬁdential medical record and will be maintained in a secure manner with access restricted to personnel involved in administering the accommodations process and individuals authorized by the ADA/ADAAA to have a legitimate reason to access such information. On an as needed basis, disability information may be shared with workforce development professionals and community partners who work together in a cooperative effort to provide accommodations to customers with documented disabilities.

Review/Approval Process

After he/she receives a written or verbal Reasonable Accommodations Request, the MWA’s EOM may take the following actions, as appropriate (NOTE: Requests shall be forwarded to the MWA’s EOM within one business day):

If it is a verbal request, record the request on the MWA’s Reasonable Accommodations Request Form, if the EOM believes written record of the request is appropriate;
Review the request for clarity and completeness and verify that the individual who has requested an accommodation has a qualifying disability (See Section II: D):
Verify a.) the essential functions of the relevant job or the service/activity requested, or b.) the facility or the area of the facility into which access is sought;
Review the information provided and consult with the requestor in an interactive process to a.) discuss speciﬁc physical or mental abilities and limitations, b.) clarify issues related to the request, c.) identify possible accommodations, and d.) assess their potential effectiveness;
If applicable, per Section II: D, request from the individual’s health care provider any additional and appropriate/relevant medical documentation that describes the nature and extent of the disability;
Consult, as necessary, with workforce partners and/ or external sources about the feasibility of accommodation strategies and explore the extent to which the accommodation can be provided

through a coordinated service approach or shared resources;

If appropriate, provide the requestor a ﬁnal verbal response, unless the request is denied or altered, in which case the decision must be in writing;
If appropriate, provide the requestor a ﬁnal, written response, which will be conveyed in a formal letter;

If the request is approved (and if the EOM determines a written response is appropriate), describe, in writing, the recommended accommodation, the rationale for the accommodation, the anticipated date the accommodation will be provided, and obtain the signature of the MWA or subrecipient’s highest level ofﬁcial;
If a request is recommended for denial or alteration, follow the guidelines in Section III of this document;
Complete the MWA’s Conﬁrmation and Review of Reasonable Accommodation Request Form, which is attached.

Determining if the Individual Requesting the Accommodation has a Disability; Requests for Medical Information

GST is entitled to know that an employee or applicant has a covered disability that requires a reasonable accommodation. If the individual has an obvious disability or previously documented medical condition that qualifies him/her as an individual with a disability and the accommodation request is related to the known disability, the accommodation request shall be considered immediately without the need for further medical documentation.

If the individual does not have an obvious disability or previously documented medical condition that qualifies him/her as an individual with a disability, he/she may be required to provide sufficient and reasonable documentation of his/her medical condition to the subrecipient/MWA representative or EOM who will determine, in consultation with the requestor’s healthcare provider, as necessary, whether the requestor is an individual with a disability. Supplemental medical information will be requested if the information submitted does not clearly explain the nature of the disability, or need for reasonable accommodation, or does not otherwise clarify how the requested accommodation will assist the employee to perform the essential functions of the job or enjoy benefits and privileges of the workplace. In the case of an applicant, relevant supplemental medical information may be requested to determine the nature of the disability or how the accommodation will assist with the application process.

The subrecipient or MWA representative, or EOM will seek information or documentation about the disability and the functional limitations from the individual, and/or ask the individual to obtain such information from an appropriate professional. Not all information need be medical, as the appropriate information may be received from a social worker or rehabilitation counselor. The documentation received must be sufficient to determine if the requestor is an individual with a disability. Additional documentation may be requested to make this determination, if necessary. In order for appropriate and useful information to be obtained, all requests should describe the nature of the individual’s job, the essential functions and any other relevant information.

If the information provided by the health professional (or the information volunteered by the individual requesting the accommodation) is insufficient to enable the subrecipient or MWA representative, or EOM to determine if the requestor has a disability, the decision maker may ask for further information. First, however, s/he will explain to the individual seeking the accommodation, in specific terms, why the information that has been provided is insufficient, what additional information is needed, and why it is necessary for a determination of the reasonable accommodation request.

The individual may then ask the health care or other appropriate professional to provide the missing information. Alternatively, the subrecipient or MWA representative and the individual requesting the accommodation may agree that the individual will sign a limited release which will permit the subrecipient or MWA representative to submit a list of specific questions to the individual’s health care professional or may otherwise contact the individual’s doctor.

The failure to provide appropriate documentation or to cooperate in the subrecipient’s or MWA’s efforts to obtain such documentation can result in a denial of the reasonable accommodation.

Scope of Approval

Where there is more than one accommodation that would allow the individual with a disability to participate in services or activities, to access a facility, or to seek employment, the MWA and its subrecipient network will consider the preference of the individual with a disability in selecting the accommodation. The MWA and its sub-recipient network are not required to provide the speciﬁc accommodation requested and may choose an equally effective accommodation that is less expensive or easier to implement.

Timeframe for Response

Every effort will be made to respond to an accommodation request in a timely manner. Generally, an agency’s decision should be issued within ﬁfteen (15) working days. If the 15-day limit cannot be met, the EOM will contact the requestor to provide a status update and establish a speciﬁc date by which notiﬁcation of the agency’s determination can be expected.

III. UNDUE HARDSHIP/ADMINISTRATIVE AGENCY REVIEW

In cases where an accommodations request involves signiﬁcant cost/impact issues, or the information provided results in a recommendation that the request be denied for undue hardship or fundamental alteration, the MWA’s Chief Executive Officer (CEO), in consultation with the, EOM will review the case ﬁle and issue an MWA determination in response to the request. Requests cannot be denied without a review by the MWA’s CEO or his/ her designee.

Factors that are considered when determining whether an accommodation would constitute an undue hardship include:

Type of accommodation requested;
The nature and net cost of the accommodation, taking into consideration

the availability of tax credits, deductions and/ or outside funding for the

accommodation;

The overall size of the employer or agency’s programs, including the

number of employees or participants, the number and type of facilities,

and the size of the budget;

The overall ﬁnancial resources of the employer or program as a whole and

the individual facility or facilities that would be involved in the provision

of the accommodation; and

The effect that providing the accommodation would have on the employer

or program or the facility’s ability to serve other customers and carry out

its mission.

Other factors that may have a bearing on whether an accommodation would create an undue hardship may be reviewed on a case-by-case basis. Any decision not to provide an accommodation because of undue hardship will be communicated in a written determination, signed by the MWA’s CEO or his / her designee and provided to the individual who requested the accommodation. All such determinations will a.) provide a rationale, and b.) identify any available alternative accommodations that could be provided, and that would not impose an undue burden or fundamentally alter the nature of the employer or the MWA’s programs and services.

OVERSIGHT / ENFORCEMENT

Individuals who a.) experience problems in receiving a response to a request for reasonable accommodation; b.) disagree with the action(s) taken by an employer or a subrecipient agency; or c.) think they may have been subjected to discrimination on the basis of disability should promptly notify:

Jerome Lewis, Equal Opportunity Manager

GST Michigan Works!

3270 Wilson St.

Marlette, MI 48453

(P) 989-635-3561 x 228

(F) 989-635-2230

Michigan Relay Center: Dial 711

jlewis@gstmiworks.org

“Supported by the State of Michigan. Equal Opportunity Employer/Program. Michigan Relay Center: Dial 711. Auxiliary aids and services are available upon request to individuals with disabilities.”

GST Michigan Works! has an established complaint procedure for addressing issues related to equal opportunity/ equal access within the workforce system that cover disputes related to the provision of reasonable accommodations. Copies of complaint procedures are available at GST Michigan Works! locations, or can be obtained by contacting the Equal Opportunity Manager.

SIGNED: ________________________________________ __________________

Jody L. Kerbyson, C.E.O. Date

GST Michigan Works!

NOTICE

Notice is hereby given to program applicants/participants/registrants, employees/applicants for employment, and the general public that all programs that are administered by the GST Michigan Works! Agency (MWA), and that are operated by the MWA’s subrecipient network comply with the following:

It is against the law for this recipient of Federal financial assistance to discriminate on the following bases: against any individual in the United States, on the basis of race, color, religion, sex (including pregnancy, childbirth, and related medical conditions, sex stereotyping, transgender status, and gender identity), national origin (including limited English proficiency), age, disability, genetics, familial status, veteran status, height, weight, arrest without conviction, political affiliation or belief, or any other characteristic or activity protected by Federal or State laws and regulations, or against any beneficiary of, applicant to, or participant in programs financially assisted under Title I of the Workforce Innovation and Opportunity Act, on the basis of the individual’s citizenship status or participation in any WIOA Title I- financially assisted program or activity.
Title VI of the Civil Rights Act of 1964, as amended, which prohibits discrimination on the basis of race, color and national origin:
The American with Disabilities Act (ADA) of 1990 – Public Law 101-336;
The Americans with Disabilities Act Amendments Act (ADAAA) of 2008
The Michigan Persons with Disabilities Civil Rights Act of 1976-Public Act 220;
Section 504 of the Rehabilitation Act of 1973, as amended, which prohibits discrimination against qualified individuals with disabilities
The Age Discrimination Act of 1975, as amended, which prohibits discrimination on the basis of age
29 CFR Part 38, Implementation of the Non-Discrimination and Equal

Opportunity Provisions of the Workforce Innovation and Opportunity Act (WIOA)

A copy of the GST Michigan Works! Agency and its subrecipient network’s Reasonable Accommodations Procedures and Policy may be obtained by contacting:

Jerome Lewis, Equal Opportunity Manager

GST Michigan Works!

3270 Wilson St.

Marlette, MI 48453

(P) 989- 635-3561 x 228

(F) 989- 635-2230

Michigan Relay Center: Dial 711

jlewis@gstmiworks.org

“Supported by the State of Michigan. Equal Opportunity Employer/ Program. Michigan Relay Center: Dial 711. Auxiliary aids and services are available upon request to individuals with disabilities.”

GST MICHIGAN WORKS!

REASONABLE ACCOMMODATION REQUEST FORM

FOR

PARTICIPANTS IN WORKFORCE DEVELOPMENT RELATED PROGRAMS, SERVICES, ACTIVITIES, OR TRAINING

Reference: Title I of the Americans with Disabilities Act of 1990 (ADA): “An individual with a disability is a person who:

Has a physical or mental impairment that substantially limits one or more major life activities;
Has a record of such an impairment; or
Is regarded as having such an impairment

(Note: Assistance, and/or auxiliary aids and services, as necessary to aid in completing this form are available upon request.)

Date: ______________ Name: ___________________________________________________

Address: ____________________________ City: ________________, MI Zip Code:_______

Phone Number: ____________________ E-mail address: _______________________________

Describe services requested/needed from GST Michigan Works! and/or its subrecipient. Examples:

job placement, computer access, self-service resources, training, etc.

______________________________________________________________________________

Describe your disability and the accommodation you are requesting. Be as speciﬁc as

possible (e.g., adaptive equipment, reader, interpreter). *Attach additional sheets as necessary.

______________________________________________________________________________

Date Accommodation is Needed: ______________ (allow up to 15 business days to process the accommodation request)

If the accommodation is time sensitive, please explain:__________________________________

______________________________________________________________________________

Is the need for accommodation likely to be temporary or permanent?_______________________

If temporary, how long do you estimate the need for the accommodation?___________________

Version: 03/2017 #RRA-I: 1 of 3

Describe how your condition limits your ability to perform the essential function(s) necessary for participation in a workforce development program/service/activity/training.

__________________________________________________________________________________

Describe how your condition affects your ability to perform a major life activity. Which major life activity(s) is / are most signiﬁcantly affected? Examples of major life activities are: seeing, hearing, speaking, breathing, walking, performing manual tasks, learning, caring for yourself, or working.

__________________________________________________________________________________

Do you have documentation to support your need for accommodation?__________________________

NOTE: (We will only request medical documentation in the event we need to review such documentation as it relates to your request.)

CERTIFICATION

I certify that I have a disability or medical condition that requires reasonable accommodation, which will be met by acquiring the equipment, services, or work adjustment described above.

Signature:_______________________________________________ Date:_________________

Supported by the State of Michigan. Equal Opportunity Employer/ Program.

Michigan Relay Center: Dial 711.

Auxiliary aids and services are available upon request to individuals with disabilities.

Version: 03/2017 #RRA-I: 2 of 3

REASONABLE ACCOMMODATION REQUEST FORM

GENERAL INFORMATION

The Reasonable Accommodation Request Form is to be completed by the individual requesting accommodation (or their representative) and returned to the designated GST Michigan Works! Agency representative for forwarding to the MWA’s Equal Opportunity Manager, or the form may be submitted directly to the Equal Opportunity Manager at the address shown below.

Complete all information requested. You may attach additional sheets as necessary.

Sign and enter the date you submitted the completed form. If you are unable to sign the form, your designated representative may sign of your behalf.

CONFIDENTIALITY: Information in your request will be treated as a conﬁdential medical record.

REQUESTS FOR ADDITIONAL INFORMATION/MEDICAL DOCUMENTATION:

Where information provided on this form is not sufficient to make a determination in response to your request, you will be contacted by the Equal Opportunity Manager for clarifying information. In some cases, medical documentation from your health care professional may be requested. It is your responsibility to ensure that such information is provided for review.

NOTE: Failure to provide medical documentation, when requested, could result in the denial of

reasonable accommodation.

RESPONSE TIME:

A response to your request should be given to you within 15 business days of the date your completed accommodation request is received. If the 15 day limit cannot be met, the Equal Opportunity Manager will contact you to provide a status update and establish a specific date by which notiﬁcation of the Agency’s determination can be expected.

ADMINISTRATIVE OFFICE OVERSIGHT/REVIEW

If a response or a status update is not issued within 15 business days, or you are dissatisﬁed with

the response you may contact:

Jerome Lewis, Equal Opportunity Manager

GST Michigan Works!

3270 Wilson Street

Marlette, MI 48453

(P) 989- 635-3561 x 228

(F) 989- 635-2230

Michigan Relay Center: Dial 711

jlewis@gstmiworks.org

Supported by the State of Michigan. Equal Opportunity Employer/Program. Michigan Relay Center: Dial 711. Auxiliary aids and services are available upon request to individuals with disabilities.

Version: 03/2017 #RRA-I: 3 of 3

GST MICHIGAN WORKS!

REASONABLE ACCOMMODATION REQUEST FORM

FOR

EMPLOYEES/APPLICANTS FOR EMPLOYMENT

Reference: Title I of the Americans with Disabilities Act of 1990 (ADA): “An individual with a disability is a person who:

Has a physical or mental impairment that substantially limits one or more major life activities;
Has a record of such an impairment; or
Is regarded as having such an impairment

Note: (Assistance, and/or auxiliary aids and services, as necessary to aid in completing this form are available upon request.)

Date: ______________ Name: ___________________________________________________

Address:____________________________ City:________________, MI Zip Code:_______

Phone Number: ____________________ E-mail address:_______________________________

Job Title:________________________________________________

Describe your disability and the accommodation you are requesting. Be as specific as possible (e.g. adaptive equipment, flexible schedule, modification of specific job duties). Please attach additional sheets as necessary:______________________________________________________________

______________________________________________________________________________

Date accommodation is needed:__________(allow up to 15 business days to process the request)

If the accommodation is time sensitive, please explain:__________________________________

______________________________________________________________________________

Is the need for accommodation likely to be temporary or permanent?_______________________

If temporary, how long do you estimate the need for the accommodation?___________________

Describe how your condition limits your ability to perform the essential function(s):

______________________________________________________________________________

Version: 03/2017 #RRA-II: 1 of 3

Describe how your condition affects your ability to perform a major life activity. Which major life activity(s) is/are most significantly affected? (Examples of major life activities are seeing, hearing, speaking, breathing, walking, performing manual tasks, learning, caring for yourself, or working):

______________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________

______________________________________________________________________________

Do you have documentation to support your need for accommodation?_____________________

NOTE: (We will only request medical documentation in the event we need to review such

documentation as it relates to your request.)

CERTIFICATION

I certify that I have a disability or medical condition that requires reasonable accommodation, which will be met by acquiring the equipment, services, or work adjustment described above.

Signature:_______________________________________________ Date:_________________

Supported by the State of Michigan. Equal Opportunity Employer/ Program.

Michigan Relay Center: Dial 711.

Auxiliary aids and services are available upon request to individuals with disabilities.

Version: 03/2017 #RRA-II: 2 of 3

REASONABLE ACCOMMODATION REQUEST FORM

GENERAL INFORMATION

The Reasonable Accommodation Request Form is to be completed by the individual requesting accommodation (or their representative) and returned to the designated GST Michigan Works! Agency representative for forwarding to the MWA’s Equal Opportunity Manager, or the form may be submitted directly to the Equal Opportunity Manager at the address shown below.

Complete all information requested. You may attach additional sheets as necessary.

Sign and enter the date you submitted the completed form. If you are unable to sign the form, your designated representative may sign of your behalf.

CONFIDENTIALITY: Information in your request will be treated as a conﬁdential medical record.

REQUESTS FOR ADDITIONAL INFORMATION/MEDICAL DOCUMENTATION:

that such information is provided for review.

NOTE: Failure to provide medical documentation, when requested, could result in the denial of

reasonable accommodation.

RESPONSE TIME:

ADMINISTRATIVE OFFICE OVERSIGHT/REVIEW

If a response or a status update is not issued within 15 business days, or you are dissatisﬁed with

the response you may contact:

Jerome Lewis, Equal Opportunity Manager

GST Michigan Works!

3270 Wilson Street

Marlette, MI 48453

(P) 989- 635-3561 x 228

(F) 989- 635-2230

Michigan Relay Center: Dial 711

jlewis@gstmiworks.org

Supported by the State of Michigan. Equal Opportunity Employer/Program. Michigan Relay Center: Dial 711. Auxiliary aids and services are available upon request to individuals with disabilities.

Version: 03/2017 #RRA-II: 3 of 3

GST MICHIGAN WORKS!

REASONABLE ACCOMMODATION

REVIEW & DECISION

Requestor’s Name: ____________________________ Date Request Received:______________

Address:____________________________ City:__________________, MI Zip Code:_______

Phone Number:____________________________ E-mail:______________________________

Does the individual have a qualifying disability?_____

If so, identify it:_________________________________________________________________

______________________________________________________________________________

Date medical information was requested, if applicable:______________

Date medical information was received, if applicable:_______________

Date accommodation request was discussed with the individual, if applicable:_______________

Brief description of the reasonable accommodation requested:____________________________

______________________________________________________________________________

Can the individual perform the essential functions of the job/ program/ activity when

provided a reasonable accommodation?_______ Explain, by giving facts, not opinions:________

______________________________________________________________________________

List reasonable accommodation options:_____________________________________________

______________________________________________________________________________

Version: 03/2017 #RD: 1 of 2

Identify any partner agencies, organizations and / or web sites that were contacted to

provide services, technical assistance, or resources:____________________________________

_____________________________________________________________________________

All accommodation requests should be processed within 15 working days. Explain any

special circumstances that caused a delay in processing this request:_______________________

_____________________________________________________________________________

Date that the individual was notiﬁed of the delay:__________________________

Request for Reasonable Accommodation Is……..

Granted * 2. Denied * 3. Altered

*The MWA CEO or his/her designee must be notiﬁed before a request can be denied or fundamentally altered.

If granted, indicate what accommodation was/will be provided and when. If denied or altered, explain the rationale for this decision:_______________________________________________

_____________________________________________________________________________

Signature:____________________________________________ Date:__________________

Title:________________________________________________

*If request was denied or altered, the MWA CEO or designee signature is required.

Signature:____________________________________________ Date:__________________

Title:________________________________________________

Version: 03/2017 #RD: 2 of 2