ATTACHMENT A

Resident Name ___________________________Resident # _________ Date:______

Federal law requires Youth Services International, Inc., to furnish appropriate auxiliary aids and services where necessary to ensure effective communication with individuals with disabilities. Such auxiliary aids and services may include: qualified sign language or oral interpreters, notetakers, computer-assisted real time transcription services, written materials, telephone handset amplifiers, assistive listening devices, assistive listening systems, telephones compatible with hearing aids, closed caption decoders, open and closed captioning, videotext displays, and TTYs.

_____ I do not request auxiliary aids or services.
_____ I request auxiliary aids and services as follows:

Resident signature: ________________________

Parent signature (if appropriate): _____________________

State juvenile justice agency signature (if appropriate): _____________________

Assisting Staff (if appropriate): ____________________

Auxiliary Aid Determination

The auxiliary aids and services requested by the resident have been:

_____ Approved as requested.

_____ Approved as modified below:

_____ Denied. Reasons for denial specified below:

Signature of ADA Coordinator: __________________ Date: _____________