Date: _______________________ Time: _______________

To: _________________________ Given to: __________________________

(Name of Agency, Organization, Business) (Name of person receiving this Notice)

I am a Deaf person who has requested under all applicable state and federal laws, the services of a qualified Sign Language Interpreter as a reasonable accommodation on the basis of my disability. I wish to have equal access to communication. I have the right to effective communication. The interpreter who has been provided to me here, (name of interpreter) ________________________, does not meet my needs and does not provide me with effective communication. I need an interpreter who can (explain what is needed) __________________________________________________________________________


This is to place you on notice that my rights are being violated because I do not have effective communication. Please replace this interpreter with one who can provide me with effective communication. Until such an interpreter is provided, you are on notice that I do not have effective communication.

(Print Name)


Title II, Section 35.104, Definitions, of the ADA provides: "A qualified interpreter means an interpreter who is able to interpret effectively, accurately, and impartially both receptively and expressively, using any necessary specialized vocabulary." Guidance from the Department of Justice further provides, "This definition focuses on the actual ability of the interpreter in a particular interpreting context to facilitate effective communication between the public entity and the individual with disabilities . . . The definition of "qualified interpreter" in this rule does not invalidate or limit standards for interpreting services of any State or local law that are equal to or more stringent than those imposed by this definition." (See

Copyright Celeste Johnson, 2003. Reprinted with permission. This form may be freely reproduced and distributed on the condition that this notice appears on all copies.