[DC GOVERNMENT] Effective Communication Program: Accessibility Request Form

Effective Communication Program: Accessibility Request Form

* Required Fields

Date of Request

Agency/Requestor Information

Agency

Phone Number

Event Logistics Point of Contact

Point of Contact Phone Number

Point of Contact Email

Event Information

Title of Event

Event Date

Time Event Starts HH:MM AM/PM)

Time Event Ends (HH:MM AM/PM)

Event Details

What is the format of the event? (Examples: Business meeting, training, classroom, legal, medical, conference, presentation, performance, speech, PTA meeting, parent-teacher conference, job interview, outside event, small group discussion, one-on-one meeting, interview group meeting, panel discussion, opening session, breakout sessions, etc.)

Approximate number of people attending event

List any VIPs (Mayor, Deputy Mayor, Agency Directors, Corporate Sponsors, etc.)

Point of Contact at event location for Interpreters/Captioners (FYI: Please schedule time for the set-up of interpreters/captioners to take place 15-20 minutes before the event starts)

Event Security Measures/Concerns (FYI: Mention if there is a badge/ID provided for interpreters/captioners)

List nearest parking availability

List nearest metro stations

Interpreter/captioner Attire for Event(s): Formal, Professional, Casual, etc.

Please attach any materials for the event (i.e. PowerPoints, Presentation Notes, Agenda, Event Memo) or email it to [email protected]

Click Here to Upload

Are there any additional materials for the event?

Yes

Please attach any materials for the event (i.e. PowerPoints, Presentation Notes, Agenda, Event Memo) or email it to [email protected]

Click Here to Upload

Event Attendee RSVP Specifics

Specific Event Attendee Requests - Type(s) of communication accessibility requested by attendees/registrants: Captions/CART, ASL/American Sign Language, PTASL/ProTactile American Sign Language, CDI/Certified Deaf Interpreter, Low Vision Deaf Interpreter, Signed Exact English, Pidgin Signed English, Induction Loops, FM Systems, IR Systems, etc.

Participant type(s): (Audience Member, Speaker, Panelists, Multiple Participants)

Participant(s) contact information icluding Name, Phone Number and Email (if applicable)

“Payment for the services shall be made through Intra-District advances by the participating agencies to MODDHH in the amounts set forth in the signed MOU, and any subsequent addendum. The participating agencies shall transfer funds within ten (10) business days of the invoice.”

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