[DC GOVERNMENT] Emergency Activation Effective Communication Program: Accessibility Request Form

Emergency Activation Effective Communication Program: Accessibility Request Form

The Emergency Activation Effective Communication Program Accessibility Request Form is for Emergency or Safety-Related events. Safety-related events include smoke alarm or strobe light installation or situations that may lead to an immediate emergency. If you do not need effective communication accessibility needs for an emergency activation or safety-related event, please fill out the General Effective Communication Program Accessibility Request Form

* Required Fields

Date of Request

Agency/Requestor Information

Agency

Phone Number

Disability Coordinator Point of Contact

Disability Coordinator Point of Contact Phone Number

Disability Coordinator Point of Contact Email

Event Information

Please note: If multiple days of effective communication accessibility needs are required, please fill out separate request forms for each day.

Event Date

Time Event Starts HH:MM AM/PM)

Time Event Ends (HH:MM AM/PM)

Description and Circumstances of Emergency or Safety-Related Event

Emergency and Safety-Related Event Details

What is the format of the event?(Examples: Emergency activation event, shelter, hospital, pop-up emergency center, outside event, smoke alarm or strobe light installation, etc.)

Approximate number of people who have effective communication accessibility needs at the emergency event site or safety-related event.

Point of Contact at event location(s) 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 Safety and Security Measures/Concerns (FYI: Mention if there is a badge/ID provided for interpreters/captioners)

List nearest parking availability – Please note any known road closures, alternative routes, or alternative transportation methods to take if necessary.

List nearest metro stations – Please note any known metro closures, alternative routes, or alternative transportation methods to take if necessary.

Interpreter/captioner Attire for Event(s): Weather-Related: hot, cold, storm, fire, etc. OR Formal, Professional, Casual, etc.

Will Interpreters/captioners be on camera or live feed during the event(s)?

Camera

Life Feed

Other

None

If Other, Please explain

If there are materials for the event (i.e. PowerPoints, Presentation Notes, Agenda, Event Memo, Links to Road Closures, Emergency Alerts, Website Information Necessary) attach to here or email it to [email protected]

Click Here to Upload

Are there any additional materials for the event?

Yes

Click Here to Upload

Event Attendee RSVP Specifics

Type(s) of communication accessibility requested by constituent: Strobe Light Installation, 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, Multiple Participants, General Information and Announcements, Receiving Medical Treatment, Injured Person, 1:1 Conversations, Large Shelter Gathering, etc.)

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

All communications accessibility/sign language interpreter requests must be sent via Online or [email protected]

“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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