| To: _______________________________
(Name of person receiving this notice)
Of: _______________________________ (Name
of agency/business/organization)
Date and Time: _____________________
Under all applicable state and federal law, I made a request
to (name of person)_________________ of this (name)
________________________ agency/business/organization, for sign language
interpreter services, as a reasonable accommodation. I informed (name)_________________________
that the interpreter provided to me, (name)___________________,
does not meet my needs and does not provide me with effective communication,
and requested that I be provide with one who does. (Name
of person) ________________________ told me to direct my complaints
to the interpreter referral/service agency (name of agency,
if known) _________________________, with which you have a contract
to provide interpreter services here. Please be advised that I have no
agreement or relationship with any interpreter referral/service agency,
nor am I a party to any contract with any interpreter referral/service
agency. I will not discuss the violation of my rights with any interpreter
referral/service agency. This agency/business/organization has the obligation
to provide me with effective communication, pursuant to all applicable
state and federal law. Please do so.
_________________________________
(Print Name)
_________________________________
(Signature)
|